Laserfiche WebLink
• <br /> OF ,OFFICE USE: ICT <br /> SAN JOAQUIN LOCAL HEALTH DISTRHazelton <br /> 2601 E. <br /> on Ave. , Stockton, Calif <br /> Telephone: <br /> (209) 466-6781 �f/1 <br /> APPLIC � N ��6 <br /> ATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> Application is Hereby made to the San <br /> (Complete In <br /> Local rHealthtDistri <br /> and/or install the work herein described. a permit <br /> County Ordinance No. 1862 and the Rules andTReguaapplication <br /> plicatiions ntis made inrc mpliancetwithnSanstruct <br /> Joaquin <br /> his <br /> e San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> 'S .4 <br /> Owner' 915C. <br /> LQ/1/CENSUS TRACT <br /> s Name /G r /TE <br /> G Phone yD� <br /> Address �'3-Z6 <br /> • o <br /> Contractor's Name City SAN-e#+AeZ1-1V <br /> .License �� <br /> D79y Phone CfZE <br /> TYPE OF WORK (Check) ; NEW WELL <br /> / / DEEPEN / / RECONDITION _ <br /> Pte' INSTALLATION pUi� REPAIR /_7 DESTRUCTION /7 <br /> Other /% / PUMP REPLACEMENT /- O <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWAGE DISPOSAL FIELDWER LINES PIT PRIVY <br /> PROPERTY LINE - PRIVATE DOMESTIC CESSPOOL/SEEPAGEPUBLIC Dp OTHER <br /> INTENDED USE TYPE OF WELL MESTIC WELL , <br /> _ Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool/public , Driven g <br /> ' Dia:. of.Well Excavation <br /> Domestic/private �-�^- �_� <br /> Domestic +"' r Drilled Dia. of Well Casing,: � � ��.-` � <br /> Irrigation Gauge of Casing <br /> Cathodic Protefction Gravel Pack Depth of Grout Seal. <br /> DiP Rotary Type of Grout ; <br /> s osa7. <br /> Gedphysical , Other Other Information f <br /> Surface Seal Installed B <br />'UMP INSTALLATION,: — ' <br /> .A .Contractor <br /> Type; of Pump <br /> H.P. <br />'UMP REPLACEMENT: L a,.\ 3 <br /> / / State Work Done <br />'UMP :REPA-IR - <br /> r State Work Done <br /> ES•TRUCTION OF- WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depfh <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Healt <br /> id the State of California pertaining to or regulating well construction. h District <br /> Eter Completion of my work on a new well, I will furnish the San Joaquin Local hin FI District a <br />,LL DRILLERS REPORT of the well and notify them before putting the well in use. <br /> iformation is true to the best of m knowledge and belief. The above <br />.IOR TO GRO NG AND A- F y g I WILL CALL FOR A GROUT INSPECTION <br />:GNED AL 'INSP ION.- <br /> TITLE <br /> ' <br /> (DRAW °PLOT PLAN ON REVERSE SIDE) <br /> ASE I _ ' r' 'e`t F012"DEPARTMENT USE ONLY <br />'PLICATION ACCEPTED BY E .. <br /> DITIONAL COMMENTS: DATE a <br /> f:;; r;x <br /> PHASE II GROUT INTPECTIOATE <br /> PHASE FINALIN <br /> PI .eSPECTION <br /> SPECTION BY D <br /> INSPECTION BY ►. ATE <br /> E H 1426 Rev. 1-74 C '� <br />