Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT MAI( G i�- <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif <br /> Telephone: (204) 466-6781 11JJ�. �,�� v�� .F4 Cy <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP /OT Permit No..7� 917Cd <br /> ` r I <br /> THISIPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued � <br /> y� (Complete In Triplicate) ,. <br /> Application is hereby made to 'the San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereirldescribed. This application is made in compliance with San Jo4quin ` <br /> County Ordinance No. 1862 and !the Rules and Regulations of the San Joaquin Local Health District. I <br /> t <br /> JOB ADDRESS/LOCATION _ °77ta /�iyu_r .��4i�-ice 1`7q�?�ts1 CENSUS TRACT , <br /> h <br /> Owner's Name -- � , e Phoned — U2 <br /> Address 739 0 e, A-V Z� rH- ,-A-,,/) __ City 21 <br /> Contractor's Nam L'cense Phone&4S=��&?S' <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/ J RECONDITION / / DESTRUCTION /_ ` <br /> PUMP INSTDATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other P / <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK .f SEWER LINES ,4 D PIT P�tIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER - <br /> PROPERTY'LINE -» PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 0 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial [ Cable Tool Dia, of Well Excavation <br /> t/' Domestic/private A L--Drilled Dia, of Well Casing <br /> Domestic/public E Driven Gauge of Casing _ (a <br /> Irrigation [ Gravel Pack Depth of Grout Seal ., <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / /, State Work Done <br /> 1 <br /> PUMP .REPAIR.: / / State�r�D one , A,B�✓..4s <br /> D •TRUCTION OF WELL: ell Diameter <br /> � <br /> r �Ul Ap"proximat epth <br /> ,Describe Material a d Procedure <br /> I hereby agree to comply 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 a <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 OUTING D FINAL INSPE ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 <br /> APPLICATION ACCEPTED BY DATE �'/14 _77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/ NZfP CM <br />•INSPECTION BY DATE INSPECTION BY <br /> 1 ��j7`�_i <br /> E H 1426 Rev. 1-74 _ <br />