Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF 4FE'ICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. If <br /> Telephone: (209) 466-6781 c, Z, J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7/--2 y <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 77 <br /> (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local 'Health District for a permit to construct' i <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 /> JOB ADDRESS/LOCATION � � CENSUS TRACT A;--S C 6 Ar <br /> Owner's NameP hone °� Q <br /> Address City�� 4,0� <br /> S 7''Q <br /> Contractor's Name �,,_License 11,3 F5 Phone?Y?Q-39 <br /> r � <br /> TYPE OF WORK (Check) : NEW WELL /tT'DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /L/'PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / / [j <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES PIT PRIVYAAjj j <br /> SEWAGE DISPOSAL FIELD/t-e".e__ CESSPOOL/SEEPAGE Pft. OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL = PUBLIC DOMESTIC WELL — , V� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 71 <br /> Domestic/private Drilled Dia. of Well Casing (o � <br /> Domestic/public Driven Gauge of Casing .11;2- 4 <br /> Irrigation Gravel Pack Depth of Grout Seal d <br /> -Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information `', <br /> Geophysical Surf J Installed B P, S- /M C, <br /> PUMP INSTALL ION: Cantractor ..r - - -- -QT - ' - c ' <br /> Type of Pump U H. . / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP�REPAIR: / f State Work Done <br /> I <br /> DESTRUCTION OF WELL Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well •'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a j <br /> WELL DRILLERS REPORT of the well and notify them- before putting the well in use. The above <br /> inform ' n is true to themesMPN----71- <br /> SIGNEDk-3) <br /> nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TTr <br /> O TING AND A F ALiTITLE <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> -� FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C�2 9 _ DATE a <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE Ij IjfFINAL INSPECTION <br /> INSPECTION BY - DATE ,r =jLL -INSPECTION BY jj✓ DATE 20 <br /> E H 1426 Rev. 1-74� -�d�n� ., �.� ..,o��o�,, .r �e',s. J� �7�. <br />