Laserfiche WebLink
-4 X SAN JOAQUIN LOCAL HEALTH DISTRICT - - <br /> FGRiOFFIGE USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 -. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 O <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-z 9__rq <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sat: Joaquin Local Health District for a permit to construct 1 <br /> and/or install the -work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Mules and Regulations// of the San Joaquin Local ]Health District. <br /> JOB ADDRESS/LOCATION - r 1 0� �S �S�• Dn A., CENSUS TRACT <br /> Owner°s Name [7 Phone Q <br /> Address " �'6�< L _ �" ' - -- - city <br /> Contractor s Name N License ���Phone �_ S-o2C <br /> TYPE OF WORK (Check): c{,NEW .WEDL /� DEEPEN '/-7 RECONDITION /? DESTRUCTION 1j <br /> 4 PUMP INSTALLATION / / PUMP REPAIR Al PUMP REPLACEMENT I=T <br /> r--Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE OF WELL -# CONSTRUCTION SPECIFICATIONS Uj <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled r Dia. of Well Casing <br /> Domestic/public 'Driven Gauge of Casing <br /> Irrigationt � y Gravel Pack Depth of Grout Seal <br /> Cathodic Protection,, Rotary Type of Grout <br /> Disposal , Other Other Information <br /> Geophysical: �~ Surface Seal Installed By: <br /> k PUMP INSTALLATION: Contractor <br /> Type of Pump R H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> t PUbT REPAIR: -� T-� ' State Work Done E <br /> 4ES;TRUCTION OFWELL: Well Diameter _ App-roximatc,Depth <br /> Describe Material and 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 t1W,Sah-JoaquinjLocal- 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GE9EING AND A F AL ZNSPECTION, <br /> SIGNED TITLE <br /> 4 (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO DEP T USE ONLY <br /> PHASE I <br /> I APPLICATION ACCEP ATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I F INSPECTION <br /> INSPECTION BY ATE INSPEC ON- BY TE "Z <br /> 1 E H 1426 Rev. 1-74 1-74 2m <br />