Laserfiche WebLink
SA' TOAQUIN LOCAL HEALTH DISTRICT <br /> FOS,OFFICE USE: 1601 lsr Hazelton Ave. , Stockton, Calif." <br /> Telephone: •(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit, No. = 7 CU <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued RL-,22- <br /> 2 <br /> (Complete In Triplicate) <br /> Application is hertby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is ta4 /in compliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the 'San aoaquin Local Health District. <br /> JOB ADDRESS/LOCATION 25/5-0 $, MQPLg5 1 CENSUS TRACT <br /> Owner's Name SA k C Al FE v W.SE Phone 47329;? <br /> Address City zvy:G,yy <br /> Contractor'a Name AIi24C K AL!,IV19 fNE„ License #,� Phone -- ,' r7 <br /> 1RPE OF WORK (Check) : NEW WELL N DEEPEN 7 RECONDITION /7 DESTRUCTION l <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _:5:22 PIT PRIVY G <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER U <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL-- <br /> INTENDED <br /> ELL —INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia. of Well Casing /(jam <br /> Domestic/public Driven Gauge of Casing /D jr�Aq, <br /> Irrigation Gravel Pack Depth of Grout Seal ,Tp � <br /> Cathodic Protection _< Rotary Type of Grout 5.r VO / <br /> 7- <br /> Disposal Other Other Information C <br /> Geophysical Surface Seal Inst/alled By: �L' mil:: .<� <br /> 'UMP INSTALLATION: Contractor 41 /✓ / y �/' �� --� �' '' 1 t 1 -^— <br /> GYI ✓,. <br /> Type of Pump 1s H.P. 17 Z <br /> 'UMP REPLACEMENT: / / State Work Done <br /> 'JIP :REPAIR: /7 State Work Done <br /> )ESTRUCTION 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 /> ind the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> -nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPE ION. <br /> SIGNED /7 <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 'RASE I <br /> XPLICATION ACCEPTED BY _` ':f s r>.*G>i7� DATE A -ya 77 <br /> MDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE42I /FINAL/ INSPECTION <br /> INSPECTION BY DATE J INSPECTION BY a,V .+DATE - - <br /> E H 1426 Rev. 1-74 V �� � �"r�JA _}) 1-74 2M4-,RS <br />