Laserfiche WebLink
r � SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 11-2-W-5 l <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , <br /> �9 <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health ` 24V�� <br /> District for a permit to construct <br /> This application is made in compliance with San Joaquin <br /> and/or install the work herein described. I <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> f;2-g 33 3 S , F:4.c <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name j Ic� a Q Phone .�� <br /> Address 9 5736-o <br /> City 66 64. i <br /> Contractor's ,Name:` <br /> f License ( phone - 639 <br /> � f <br /> TYPE OF WORKS (Check) :_ NEW WELLr/� r DEEB'-EN-/ / ';RECONDITION /7 --DESTRUCTION/� <br /> 1 _ <br /> PUMP INSTALLATION /7 PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> f / / Other101 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY y E <br /> SEWAGE DI 5 OSAL FIELD ESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL `—` PUBLIC DOMESTIC WELL `---- .. <br /> INTENVh.V USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSIrtdu <br /> al <br /> ome stic/p ` Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack L,,,,Dep'th of Grout Sea <br /> Cathodic Protection ary Type of Grout <br /> Disposal + Other Other-�Information - T'f— -Xi-e <br /> Geophysical <br /> ►_ urf ce .Seal' I lied n- <br /> or <br /> PUMP INSTAL � or <br /> Contract CATION: Contrati <br /> I Type of Pump <br /> � <br /> f <br />??P\REPLACEMENT: ` <br /> / / State Work Done <br />'UMP .REPAIR: State Work Done . . <br /> IES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material 'and Procedure 4. <br /> hereby agree to comply with all laws and -regulations of the San Joaquin Local Health District <br /> end the State of California pertaining to ori-,regulating well construction. Within FIFTEEN DAYS <br /> Ifter completion of my work on a_ new well, I wilt furnish the San Joaquin Local Health District a i <br /> FELL DR <br /> LLERS REPORT of the we d notify-them before - <br /> putting the. well Fin use.. The above <br /> nformat is true to the ixf m ..knowledge and-b"elief: I WILLGALL FORA GROUT INSPECTION <br /> RIOR TO GR ING AND A F ECT ' <br /> IGNE <br /> TITLE <br /> W PLOT PLAN ON REVERSE SIDE) <br /> HALE I F R DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY DATE 7 <br /> DDITIONAL COMMENTS- <br /> PH I GRO T INSPECTIO PHASE I /FINAL INSPECTION <br /> IVSPEGTZON BY V DATE -INSPECTION BY lj1/ DATE 7 �/ <br /> r <br /> �E H 1426 Rev. 1-74 2;I " ..�v ` �C.t,= s r� 1777 . <br /> - , <br />