Laserfiche WebLink
— SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FoB OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74-17Z-11 <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-20-4 <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 Health District. <br /> JOB ADDRESS/LOCATION 1/ CENSUS TRACT <br /> Owner ts Name BAE R Phone ..933-0?91 z <br /> Address ) JICity 4SC- 51 ZDA2 <br /> Contractor's Name License OPhone 509 <br /> TYPE OF-WORK (Check): NEW WELL /?- DEEPEN /� RECONDITION /?T DESTR ICTIONy/ f " - `" `- <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT 1-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSALIFIELD \ CESSPOOL/SEEPAGE PIT OTHER \ <br /> PROPERTY LINE --PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �} <br /> INTENDED USE. 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q'l <br /> Industrial Cable Tool Dia, of Well Excavation <br /> } Domestic/privateDrilled Dia. of Well Casing <br /> Domestic/public :g; -Driven �` Gauge of Casing . <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> 4 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 ; A.P. <br /> PUMP REPLACEMENT: - ;t <br /> State Work Done a , <br />—PUMP "REPAIR: State Work Done leg2A.�- <br /> W64PZ)l Ce <br /> ES�TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure a <br /> I hereby agree to comply with all laws and regulations of the Sart 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-beat of- my knowledge and belief. I WILL CALL FO A,GROUT INSPECTION <br /> PRIOR TO GROU>XNG ANDI) FI INSPECTION. <br /> SIGNED if AZ TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION- BYDATE <br /> ,E H 1426 Rev. 1-74 <br />