Laserfiche WebLink
Y Co"t- %,,SAN <br /> JpAQUIN LOCAL HEALTH DISTRICDISTRICTFO$iOFFiC USE 1 E. Razelton Ave, , Stockton, Cal:LfSCANN"'Z.=1j <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 _3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete in Triplicate) <br /> Application is hereby made to tha- /0 5'_ �CUo-13 <br /> e San Joaquin Local, ITeal.th Districs made in compliance with San Joaquin <br /> t for a Permit to construct <br /> sad/or install the work herein described. This application i <br /> County Ordinance._,N,.) _1862-and­the Rules and Regulations of theSan Joaquin Lacal Health District. <br /> jo�iJcc .� e� <br /> JOB ADDRESS/LOCATT UN¢� <br /> S o t L. <br /> 4 r 0 CENSUS TRACT <br /> Owner'e Name <br /> f Phase <br /> Address --` y _ a / <br /> City <br /> Contractor's �/�' f <br /> License 1�3 7Z,rPhoae <br /> fiyP$ OF WORK (Check): NEW WELL /? DEEPEN I / RECONDITION /? DESTRUCTION f f <br /> PUMP Zl15TALLATION /% PUMP REPAIR pUMp REPLACEMENT �" "N_ <br /> Other <br /> a � <br /> DIS CE TO NEARES' ; SEPTIC TANK . SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE CESSPOOL/SEEPAGE PIT OAR . <br /> PRIVATE DOMESTIC WELL '-- <br /> INTENDED USE - TYPE OF WELL CONSTRUG'd'ION SPECIFICATIONS <br /> ' Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/pri-vate Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of ;Grout Seal <br /> Cathodic Prot:Wcti.on Rotary Type of Grout <br /> Other Other Information <br /> Geophyaica2 Surface Seal Installed By: <br /> f PUMP INSTALLATION: Contractor -� <br /> I Type of Pump cG, <br /> I 2, 10 H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Dane ; <br /> PUMP `.REPAIR: / State l+York -Done <br /> ES;TRUCTION OF WELL: Well Diameter r <br /> Describe- Material and Procedure -Approximate Depth ^ <br /> I hereby agree to comply with all laws and regulation;; of the Sacs Joaquin Local Health DiStriCC <br /> ( and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> I after completion of my work on a new well, I will furnish the San Joaquin Local Realt <br /> ! WELL DRILLERS REPOR.F of the t., The ell and notify them before putting.. the..well in.use.. h Bove District a <br /> information is true to the-best of- my-knowledge and belief. above <br /> PRIOR TO '"ING A1iD A FINAL INSPE I WILL CALL FOR A'GROUT INSPECTIQN <br /> SIGNED Q <br /> (D W PIA PLAN ON jsz irDE ; <br /> PHASE I FOR DEPARTMENT USE ONLY — <br /> i <br /> APPLICATION ACCEPTf'_:D By <br /> F ` <br /> ADDITIONAL COMMEii'TS : DATE <br /> PHASE iI GROUT INSPECTION Pty kS <br /> INSPECTION BY <br /> DATE )rTII FINAL INSP$CTION <br /> INSPECTION• Bi DATE 47 " <br /> t <br /> 3 S H 1426 Rev. <br />