Laserfiche WebLink
__ SAN J-,IAQUIN LOCAL HEAi,TH DISTRICT <br /> FOF�.•Unf;CX USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> 91.1 :17 O . Telephone: (209) 466-6781 <br /> liPPLICATIOX FOR WELL CONSTRUGT?4N OR Pump PERttIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> u (Complete in Triplicate) <br /> Application is Hereby made to the San Joaquin Lo-,al ilcalth District for a permit to conetruct-"� <br /> uudlor install she work herein deucribed. This application is made in compliance with San Joaq,:u: <br /> County Ordinance No. 1862 and the Rulea and Regulations of the San Joaquin Local Health District. <br /> f; <br /> JOB ADDRESS/LOCATION ��C/ ��/�«vs.� �� CENSUS TRACT <br /> s O,«mar's Name I f� �� f� �� mrd► Phone <br /> Address City <br /> :,.•. Contractor'a Name {�� /��tif 1 License #:z <br /> r3 TYPE OF WORK (CI�Fck): NEW WvLL I' FiEEPEEPF '/'7 RECONDITION DESTRUCTION 7 <br /> PUMP INSTALLATION 0_ PM-fP REPAIR-/? Pm, REPLACEMEEii f7 <br /> Other F <br /> DISTANCE TO NEAitESs: EEPTIC TrUNK SINES I'1T PRIVY <br /> S:rW,A.GE DISPu}SAL )FIELD CESSPOOL/SEEPAGE PI GTHEA <br /> ?.PERM EINE ZJ'i'RT•VATE :CMESTIC WELL"_.. - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYFF OF WELL CONSTRUCTION SPECIFICATIONS ` <br /> Industrial � Cable Tool Dia. of Well Excavation .10 <br /> Domestic/privax a _._w..._ Drilled Dia. re TIM Casing <br /> ?omes-is/publicDriven Gauge ;f Casing <br /> -- - irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rnt8r7 ;ype of Gaut r <br /> Disposal Othar � Other Information <br /> —Geophysical Surface Seal Installed By: 7 a7 ti <br /> r PIR T IPISTALLA 100. Contractor <br /> — _ Type of Puri H.P. / <br /> N. Yi 1 <br /> " PMIP xZEPLA°T14': %! Stat: Work Done <br /> PUMP 'REZAIrR: � /7 State WJrk Done. <br /> :r •� <br /> 43"a �'F&TRL`C'IIG$-_OF` M1. Well Diaurster _ -�� Apl+roximate Depth� ..�_ -�-- Describe c�te..iai and ?rocefd�ure <br /> I hereby agree to comply with all lava and regulations of the San Joaquin Local Health District <br /> `.5 and the State of California pertaining to or regulating well'-construction. Wi.thiv FIFTEEN DAMS <br /> after comrilctian of m}• work �:� a new val.l, I will ffsrnxrsh the o-n Joaquin to liSalth District r: <br /> WELL DRi0.ERS REPORT of the well and notify theme before puttir_g.thE.is."e11 use.. The above <br /> information is true to the•bez- of %j knowledge and belief. . I WILL CAL OR A GROUT INSPECTION <br /> PRIOR M GROUTING AND A FI?+JekTjNS -r M, ON n <br /> SIGNED <br /> F'; - (DRAW P;.OT LAN 4N REi'L�HSF. STDFs <br /> s / FR I34MC 'SE ONLY <br /> PRASE I fffjjj L `} <br /> T4 1�PPLiCATION ACCEPT'ruD B G sem. l 4. �• r-�- ` �.� DATE -?5� - <br /> �' ADDITI[�iTAi. COH:�f£ti O: / M <br /> PHAS"'� CGRO 1ANSPECTION PHASE R1 iNAL INSDHCTI. <br /> INSPECTIONUSC�i v-DATS � � 1IiSY'BC`IIOH 8Y '' �. �,�.� DATE I ?a �_? <br /> E H 1426 Rev. .1--74 b/75 2�S <br /> `A <br /> N� <br /> �VA } <br />