Laserfiche WebLink
SAN ;IOAJUIN LOCAL"HEALTH DISTRICT <br /> FOF��!,OFFICE USE: 1601 E. Hazelton Ave. , Stockton Calif. <br /> ���� <br /> Telephone: (209) 466--6781. 77—ilL974' <br /> 4 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4,1 <br /> r� <br /> f THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued � 3�-7J <br />,r (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 in Local Health District. <br /> JOB ADDRESS/LOCATION IL SUS TRACT <br /> Owner's Name "=a Phone , <br /> 'Address - <br /> Cit <br /> Y?M�_A <br /> Contractor's Name 10 if <br /> LZZ <br /> License # X0 Phone -� <br /> TYPE OF WORK (Check): . NEW WELL ITT_DEEPEN/_7 RECONDITION %J DESTRUCTION f f <br />! PUMP INSTALLATION/ / PUMP REPAIR/_7 PUMP REPLACEMENT17 <br /> Other/ <br /> DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES <br /> µ <br /> PIT PRIVY <br /> SEWAGE-DISPOSAL-FIELD --CESSPOOL/SEEPAGE PIT OTHER` <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial � . <br /> Cable Tool Dia. of' Well Excavation � <br /> __Domestic/private A---Drilled Dia. of Well Casing Q� <br /> Dome Kic/public . <br /> -�-��Driven - - _ -� -�Gaug+e==vf=*CasiAg�� ' <br /> -- <br /> Irrigation Gravel Pack _• ; -Depth of Grout Seal _ 4_� w <br /> Cathodic Pr_otect_i_ on L -'Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Y Surface' Seal Installed '.B <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT; / / State Work Done <br /> f PUMP ,REPAIR; ' <br /> State Work Done . <br /> DES;TRUCTION OF WELL: . Well Diameter Approximate PP ximate Depth <br /> Describe Materialarid 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 CALI. FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL. iNSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE 4 <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED .� <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE Ir,,GROM-INSPZCTION HAS III INSPECTION <br /> INSPECTION BY DATE - INSPECTION BY DATE <br /> E'H 1426 Rev. 1-74 �C`"�Guell <br />