Laserfiche WebLink
4P i L 1,0 /T TD <br /> SAN JOAQUIN LOCAL HEALTH DISTR <br /> FOR [JFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.� 2r Pw <br /> Telephone : (209) 466-6781 -yS 3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,Y%z� <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> AF-; (Complete In Triplicate) ZZ7-07�i7� <br /> Appli'cation"'is hereby-raade-to-'the San Joaquin Local Health District for a permit to construct <br /> and/or install the work ,herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules ar} Re ulati n f, he S n oaquin Local Health District. <br /> JUB ADDRESS/LOCATION E cENsus TRACT <br /> Owner's Name Phone - <br /> Address City . <br /> E Contractor's Name .1t , License �� <br /> .d j Phone <br /> ff <br /> � r <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_% DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELD CONSTRUCTION SPECIFICATIONS - <br /> _ � . , -S <br /> Industri;private Cable Tool /Dia. of Well Excavation 6201 <br /> C <br /> Domestic rilled Dia. of Well Casing -- - /+ <br /> Dome.sti.c/p lic Driven Gauge of Casing IN <br /> Irrigation -`Gravel Pack Depth of Grout Seal — <br /> Cathodic Protection , ` Rotary Type of Grout — <br /> Disposal Other Other Information <br /> Geophysical A Surface Seal Installed B --f <br /> •\r-.h f `�. r L'� r' F � <br /> PUMP INSTALLATION:; rGnntracr / <br /> ►' a Type of Pump -77�'3 / D c 4 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-REPAIR: -- • : - W, ta-te-Work_,3 ne ----- <br /> �``=°� <br /> DESTRUCTION OE WELL. Well Diamete.r...--'"1 - ar. ,r - -Approximate Depth <br /> Describe Material and Procedure ' 0 'ter <br /> I hereby agree to. comp.ly with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of;,My work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND FINAL INSPECTION. <br /> SIGNED <br /> TITLE d2. eJ _ <br /> (DRAW PLOT PLANagN REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED. BY DATE �~27 7 - ` <br /> ADDITIONAL_ COMMENTS:: `�' _.= �. - n - .-r z <br /> PHASE II GROUT INSPECTION -- PHASE III FINAL INSPE TION <br /> INSPECTION BY DATE INSPECTION BY („/ DATD ;y�^] <br /> E H 1426 Rev. , 1-74 2M ..'� <br />