Laserfiche WebLink
f SAN JOAQUIN LOCAL, V,,41TH DISTRICT '`/" Y�I r € <br /> FOF OFFICE USE 1601 E. Hazelton Ave. , Stockton, Calif. - <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �72- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 67-,,)3-2,7 <br /> {Complete In Triplicate) <br /> Application is Aereb 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 1C , - Rn.ft, 0 CENSUS TRACT <br /> Owner's NamePhone 53 9-zq <br /> Address / City <br /> Contractor's Name 1 License Phone <br /> TYPE OF WORK Check) : i <br /> ( NEW WELL /�/ DEEPEN /_� RECONDITION / / DESTRUCTION /� <br /> PUMP INSTALLATION'/ / PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRTVY { <br /> • SEWAGE DISPOSAL FIELD CE55POOL/SEEPAGE PIT OTHER <br /> . PROPERTY LINE -» PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation �f <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Wad ,, x ( , <br /> Irrigation // Gravel Pack Depth of Grout Seal <br /> Cathodic Protection !/ Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION; Contractor J rTWh2,t <br /> . Type of Pump H.P <br /> PUMP:'REPLACEMENT: / / State Work Done ' <br /> PUMP '.REPAIR: State Work Done <br /> ASjRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I° hereby agree to comply with all laws and regulations of the San Joaquin Local Health 1)istrfct <br /> andethe 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 /> infprmation is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION , <br />'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> 31GNED TITLE1. <br /> (D PLOT PLAN ONERSE SID-ET- <br />?RASE <br /> IDE'RASE I , <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY G DATE <br /> dDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEW/FINAL PHASE /FINALINSPECTION <br /> ENSPECTION BY DATE INSPECTION BY DATE ' <br /> E H 1426 Rev. 1-74 1f/7. _ 2M <br />