Laserfiche WebLink
-- i <br /> SAN JOAQUIN' LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOF�iZFFICE USE: Telephoner (2O9) 466-67$1 <br /> SS <br /> APFLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Issue <br /> Date d <br /> EXPIRES 1 YEAR <br /> THIS PERMIT AR FROM DATE ISSUED �L--- . <br /> (Complete In Triplicate) D 6 I 0—32, <br /> T <br /> application �s made in compliance with San Joaquin ! <br /> A lication is here made to the San Joaquincal. Health District for a pex�nit to eaue ruc District. <br /> PA <br /> and/or install .the,work herein described. ThisPP <br /> County_,Ordinance No., 1862 and the Rules.and Regulations of the San Joaquin Local Health Distr 4 <br /> Y" CENSUS TRACT <br /> J B 'ADDRE_SS/LOCATION <br /> e , Phone Z 4 <br /> Owner's Name <br /> City La__ - <br /> Address �/ _�^��� <br /> License #/4-237 Fhone3 E' <br /> Contractor's Name <br /> I ck : - NEW WELL /7 DEEPEN / RECONDITION /-7 DESTRUCTION <br /> f7/7 <br /> TYPE OF WORK (Che )-y PUMP INSTALLATION PUMP REPAIR Pte' (� <br /> ....,' Other <br /> IT PRIVY <br /> SEWER;LINES OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/.SEEPAGE PIT :,_ <br /> -«r - SEWAGE DISPOSAL FIELDY PUBLIC DOMESTIC WELL I� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> - ' .INTENDED USE tion <br /> TYPE OF WELL .. <br /> Cable Tool Dia. of Well Excava <br /> f Industrial Drilled Dia -of Well Casing <br /> — Domestic/private --- Driven Gauge of'-Casing <br /> Domestic/public De Depth of Grout Seal <br /> p <br /> irrigation Gravel Pack e of Grout <br /> Cathodic Protection Rotary Other Information <br /> _._._.�..- Disposal Other <br /> -�� Surface Seal. Installed B <br /> ��Geophy6ica3 . <br /> PUMP INSTALLATION: Contractor H.P. - <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done <br /> / Sate Work Done <br /> PU10--. LFAIRa�"f a r <br /> Approximate DepthWell iameter <br /> DES:TRUCTION OF WELL: Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the1San'Jocti n Local <br /> WithinaFIFTEEN DAYS <br /> and the State of California pertaining to or regulating well construction. <br /> after co letion of my work on a new well, I will furnish ut a SahJowelZninouse.. The h above + <br /> a mP <br /> WELL DRILLERS REPORT of the well and notify them before p <br /> ,information is true to the-best of my knowledge and belief. I WILL CALL FOR,A GROUT INSPECTION <br /> 1 PRIOR TO GRO G D A FINAL- INSPECT ON. TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> % FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> . � DATE <br /> APPLICATION ACCEPTED BY ��' - <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II ROUT INSPECTION INSPECTION BY DATE / .lam <br /> 1NSPECTION BY DATE _ <br /> 1-74 2M <br /> E H 1426 Rev. 1-74 f _ - <br />