Laserfiche WebLink
{t <br /> ., SAN i(YAOIN LOCAL -HEALTH DISTRICT <br /> FOA r_gFF'ICE- USE: '1601 E. Hazelton'Ave. , Stockton, Calif. <br /> Telephoned " (209) .466-6781 :QW <br /> 0 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Nov <br /> ZL 21Cry <br /> ,il: <br /> THIS PERMIT EXPIRES 1 YEA.R-'PR0M DATE ISSUED Date Issued 6- 30-/t/, <br /> (Complete Iri°Triplicate) <br /> Appligdtion is hereby made to the San Joaquin Local 'Health District for a permit to construct k <br /> and/or install the work herein described. This application is made in compliance with San Joaquin' <br /> Count' Ordinancce„ No. 1862 and the Rules- and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESSAOCATION _ _ CENSUS TRACT <br /> Owner'a Name Phone <br /> Addre s City <br /> Contrllctor'a Name <br /> �p License �4�� Phone <br /> TYPBOF WORK (Check): NEW WELLDEEPEN /7 RECONDITION /7 DESTRUCTION _ <br /> PUMP.. INSTALLATION / J PUMP REPAIR /�PUMP REPLACEMEN /7 <br /> Other /•,/ <br /> . ; <br /> DISTANCE TO NEAREST: . SEPTIC TANK',t SEWER;LINES � : iPIT PRIVY <br /> SEWAGE DISPOSAL FIELD '; CESSPOOL/SEEPAGE PIT OTHER <br /> �4 PROPERTY"LINE -- PRIVATE- DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> 'iJINTENDED USE TYPE OF WELL , CONSTRUCTION SPECIFICATIONS <br /> _F Industrial = Cable Tool .Dia,.t of Well Excavation <br /> V,Domestic/private Drilled "Dia. 'of Well' Casing <br /> Domestic/public Driven Gauge--o€ Casing` <br /> Irrigation Gravel Pack Depth. of'=Grout Seal � --6 I ,A i <br /> 41Cathodic Protection* Rotary Type of Grout` <br /> Disposal Other Other' infor"tian <br /> • eophysica,i ► '- Surface Seal Installed By: <br /> PUMP Ia STALLATION t{ ,�- Contractor <br /> b ' Type.of Pump og V <br /> �� H.F. <br /> PUMP REPLACEMENT: %JJ State Work }ane-_ <br /> PUMP <br /> REPAIR: - <br /> L7 State Work Done <br /> M-TRUCTION 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 ttie 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well, in,;use.. The above <br /> information is true to the-best of. my.knowledge and belief. I WILL CALL FOR •A -GROUT INSPECT ON <br /> PRIOR TO GROUTING AND A FIN INSP CTIML <br /> SIGNED' TITLE "!`-�'"�rt <br /> �1 DRAW PLOT PLAN ON REVERSE SIDE <br /> I�! <br /> FORPDPARTHENTiUSE ONLY <br /> PHASE yj <br /> �tj- <br /> APPLICATIQN ACCEPtF $Y DATE <br /> ADDITIONAL COMMENTS: . f <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPEC• ION BY DATE INSPECTION- BY DATE <br /> 7 J61 77 lky�l <br /> E H 1426 / - <br /> Rev. 1- <br /> II 74 f K 1-74 2M <br />