Laserfiche WebLink
et <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> {1601 E. Hazelton Ave., Stockton, Calif. <br /> } Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /.a-7-7.5 <br /> I (Complete In Triplicate) <br /> Application 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> } <br /> JOB ADDRESS/LOCATION _.Apw . tLA,Jm A/ Q X ,/�O ,e � �� CENSUS //TR,,ACT O 5 <br /> Owner's Name n4//}} t_.s r .�[ Phone 7�.�2 <br /> Address �T— <br /> � i 1 12)// 0AA)j0 A . 1( 172ZASP City <br /> Contractor's Name ac License 013 phone <br /> TYPE OF WORK (Check): NEW WELLTDEEPEN ,/-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION F7 PUMP REPAIR _/ PUMP REPLACEMENT LY <br /> Other/7 <br /> DISTANCE TO NEAREST: SEPTIC'TA&K SHWER LINES PIT PRIVY <br /> SEWAGEiDISPOSAL FIELD CESSPOOL/SEEPAGE PZT OTHER <br /> PROPERTY LINE - PRIVAT$ DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial : Cable Tool Dia, of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing tN <br /> Domestic/public \ i Driven Gauge of Casing Pv <br /> Irrigation � ; Gravel Pack --,Depth of Grout Seal �L1 <br /> Cathodic-Protection '71Rotary Type of Grout <br /> Disposal ' t Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION; Contractor <br /> Type of P!xmp ? 1P3 H.P. <br /> PUMP REPLACEMENT: / / Sitate Work Done <br /> PUMP :BEPAIR �7 State Work Done 0 tzA <br /> DESTRUCTION OF WELL; Well Diameter Approximate Depth <br /> Describe Material and Procedure \` <br /> I hereby agree to comply with; all laws andregulations of the San Joaquin Local Health District 1 <br /> and the State. of California pertaining to or regulating well construction. Within FIFTEEN DAYS 1 <br /> after completion1of my.work on,a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the will and notify them before putting. the well in use.. The above <br /> information is true to the best of mg, Is ge.dfi"d lief I WILL CALL FOR A GROUT INSPHCTIN <br /> PRIOR TO ING'AND FINAL) ON <br /> O <br /> SIGNED - <br /> ITLE ��.&- <br /> LAN ON E SIDE— 1 <br /> PEASE S <br /> Y EPAR T USE ONLY <br /> APPLICATION ACCEPT CO i DATE ��` - -3 <br /> IONAL COMMENTS: 1 <br /> PHASE IZ UT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 9 / <br /> E H 1426 Rev. 1-74 <br />