Laserfiche WebLink
EFOR- -OFFICE 5� , SANJOAQUIN LOCAL HEALTH DISTRICT1601 E. Hazelton Ave. , Stockton, CalTelephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit <br /> Pd� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDApplication is hereb I (Complete In Trlicate) Date Issued� 7, <br /> e tip <br /> o the San Joaquin Local Health District for a <br /> struct <br /> and/or install the work herein described. This application permit to <br /> } County Ordinance No. 1862 and the Rules and Regulaionsofthe Sanis eJoa Jin oaquin <br /> HeatttnS District.� �quin <br /> r q cal Health District. <br /> JOB ADDRESS/LOCATION - <br /> " � �s <br /> � Owner's Name ENSUS TRACT�G / MDP <br /> ! Address s N` Phone .l.�.Z <br /> 04i <br /> Contractor' Name �/� �� 10, a •s �^ i <br /> w�T License 4tphone 62g-71f3Z1 <br /> TYPE OF WORK (Check): ,:NEW WELL / DEEPEN r <br /> /7 RECONDITION /7 DESTRUCTION /� } <br /> ti PUMP I <br /> NS AL TION PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <br /> • Other / / L <br /> DISTANCE TO NEAREST: SEPTIC TO <br /> SEWAGE DISPOSAL FIELDER LISEKNES PIT PRIVY <br /> PROPERTY LLATE - PRIVATE DOMESTICCESSWELOL/SEEPAPU LIC DOMESTICOTHER <br /> INTENDED USE "rz OF WELL WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Domestic/private Cable Tool 's Dia. of Well Excavation <br /> t� Drilled Dia, of Well Casing <br /> Domestic/public 1 Driven ti <br /> .Irrigation ;Gauge of Casing <br /> Cathodic Protection Gravel Pack Depth of Grout Seal <br /> Dis osal i� Rotary _• �, Type of Grout <br /> p <br /> Geophysical Other ' Other Information <br /> Surface Seal Installed By: <br /> 'UMP INSTALLATION- Contractor , <br /> Type of `Pump 5' <br /> E H.P. <br /> ' REPLACEMENT: SZ 7 6 <br /> / / tate Work Done <br /> .REPAIR: State Woo k Done <br /> ESTRUCTION OF WELL Well Diameter <br /> Approximate-D' <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> Eter comp' etion of my work on a newwell, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them_'before putting the. well in use.. <br /> formation is..•t.ru above <br /> ,IOR T e_.to the_best.,Of. my..knowle.dge-and_belief..—I -WILL .CALL-FOR -A GROUT eINSPECTIO <br /> ROUTIN AND A NAL INSPECTION. <br /> IGNED <br /> TITLE iLJ E <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> [ <br /> EASE I FOR DEPARTMENT USE ONLY 1 <br /> [ I <br /> 'PLICATION ACCEPTS y G✓/� ` <br /> DITIONAL -7-7COMMEN DATE _ r'�� <br /> P�HA �IIGRO�UTTNSP$CTION PHASE INAL NSPECTION <br /> SPECTION BY ATES G INSPECTION BYTE 2--771-6 <br /> .E. H .1426 Rev. 1-74 <br />