Laserfiche WebLink
�L JOAQUIN LOCAL HEALTH DISTRIC 00 � <br /> 'OFFICE USE: V 1601�E. Hazelton Ave. , Stockton, Cali If <br /> Telephone: (209) 466-6781 f.l <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 741--3-5,3 4� <br /> ';�v -:L�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> 4pplication 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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LO,CACA/TION >2 �� <br /> A CENSUS TRACT <br /> Khmer's Name f/ / ��� �i�0 dUCi�SPh <br /> Phone <br /> address ✓52 I'S bs '5;2' /L�`N r13 y � City <br /> /b 5. 3 9 2f <br /> :ont <br /> ;ac or Name License 0 Phone <br /> 'YPE OF WORK (Check) : NEW WELL DEEPEN /_7 RECONDITION /-J DESTRUCTION <br /> PUMPOtheINSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> I �p <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWE�RIIL''I.jiTE / PIT PRIVY "1 <br /> SEWAGE DISPOSAL FIELD -PP""'�'CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL_g <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC§IjOpS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /40 <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> _, Cathodic Protection X Rotary Type of Grout / <br /> TL <br /> —Disposal Other Other Information <br /> —Geophysical Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor a�tT� pe_j" fv�s <br /> Type of Pump '7"41 /fv H.P. <br /> UMP REPLACEMENT: /_/ State Work Done <br /> UMP '.REPAIR: /_7 State Work Done <br /> E_STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ad the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> [ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 71LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> aformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> :IOR TO GROUTING AND A FINAL INSPECTION. <br /> CGNED /�„� ,� y - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> iASE I <br /> � � FOR ARTMENT USE ONLY <br /> 'PLICATION ACCEPTED BY / > / J, : / Z-. / I. DATE 7- <br /> )DITIONAL COMMENTS: tl <br /> PHASE II GROUT INSPECTION PHASE I I F AL IN <br /> ISPECTION BY DATE INSPECTION BY DATE Z� <br /> E H 1426 Rev. 1-74 <br /> t-7L 7M <br />