Laserfiche WebLink
a` <br /> FOR OFFICE 35E• /�1161601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 7;7- ,5 Sfk11 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S—_?/-7/7 <br /> (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 herein described. This application is made in compliance with San Joaquin , <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local He5lth District. <br /> JOB ADDRESS/LOCATcs <br /> v Z V <br /> US TRAC <br /> i Owner's Name �[ Phone 1 <br /> AddressCity <br /> Contractor's Name ZJ BA License - - honey <br /> i TYPE OF WORK (Check) :­NEW WELL~� DEEPEN "/ / RECONDITION %;7`'j DES'TRUC-TION <br /> PUMP INSTALLATION / ./ PUMP REPAIR. /7­/ <br /> PUMP t MP !REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE -PIT �- BOTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC TIONS <br /> Industrial "able Tool Dia, of Well Excavation <br /> Domestic/private '✓ Drilled Dia. of Weil C''asing Z�°� <br /> Do estic/public Driven Gauge of Casiri'g I ��� <br /> rrigation Gravel Pack Depth of- Grout, SeAl <br /> Cathodic Protection Rotary Type of Grout i ' <br /> Disposal I Other Other In.fbimation <br /> Geophysical Surface 5ea1 Inst•lied By: <br /> r� j► <br /> PUMP INSTALLATION: Contractor .' 1 <br /> Type of- Pump i p f H.P. <br /> PUMP REPLACEMENT: ' / / �Stat/e Work Done y' <br /> PUMP .REPAIR: Sate Work Done <br /> DESTRUCTION OF'WELL: �' Well'kDiameter ;`'Approximate Depth <br /> Describe Material and 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' Sari 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 ue to the best o my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT D 'FINAL IECTI % ; i <br /> SIGNED TITLE r` <br /> _41D-_ W-y' i ' PLAN ',ON REVERSE SIDE),r <br /> F DEPARTMENT USE ONLY <br /> PHASE I - - <br /> APPLICATION ACCEPTED BY eDATE <br /> ADDITIONAL COMMENTS: -- <br /> PHASE "II OUT INSPECTION PHASE II /FINAL INSPECTION 4 <br /> INSPECTION BY YM DATE INSPECTION BY DATE I' <br /> E H 1426 Rev. 1--74 376 2M > <br />