Laserfiche WebLink
%C. ,:i0' LOCAL 11EALT: <br /> FOR OFFICE USE: _, i6;? ti. llazciton Avc. , Stockton, Cain <br /> 1 iL-•1i I one: (209) 466-6781 <br /> AP4"LICATiON FOR w::LL CONSTRUCTION OR I'UtIP PZIIT Permit No. <br /> ills PER.`EIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4 77 <br /> (Complete In Triplicate) <br /> Application i, hereby made to the San Joaquin Lor.al Ilealth Di,,-r.ict for a permit to construct <br /> and/or install the work herein described. This application 13 ma3e in compliance with San Jcaquin <br /> County Ordinance Pio. 1862 and the Rul7s and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / ! 3. r CENSUS TRACT <br /> Owner's Name /Ela�� t L.� _ Phone <br /> Address L t :_�L �.. _ City <br /> License # Phone <br /> Contractor's Name i.f'� e,,��t}�yj;,;,u;. Cc _ S`F,-3yS�• <br /> TYPE OF :BORIC 'Check): NEW WELL / % DEEPEN /� RECONDITION /_� DESTRUC'TION /� <br /> PUMP INSIALLATICN Z&/ PUMP REPAIR / / PUMP RFrLACEMENT !-T <br /> Other <br /> DISTA10E TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSt.L FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELI, ____ PUBLIC DOMESTIC WELL <br /> i INTENDIID USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ' Indust:-ial _ Cable Too! Dia. of Well Excavation <br /> i Domestic/private Drilled Dia. of Well Casing <br /> 9W , <br /> _ Donr2stic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal _ Ilk i <br /> yCathodic Protection Rotary Type of Grout <br /> i Disposal Other _ Other Information b <br /> t Geophysical Surface Seal Installed By: s <br /> z <br /> PUMP INSTALLATION: Contractor k } j t4 e-,i A.,n 1:k he e <br /> { <br /> Type of Pump _ i �: H.P. -75 <br /> t <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: / / State Work Done <br /> J?ESTR'UCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <br /> I hereby agree to comply with al.1 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 <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 nay knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED p s.� 1,.;L. a TTTL•E <br /> (DRAW PLOT PLAN ON REVERSE SIDE7, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I --,X, <br /> PLICATION ACCEPTED BY � <br /> LD _1) / DATE <br /> � ADDITIO::AL CO;f.,;ENTS: ' <br /> PHASE_ II GROUT' INSPECTION ] II / PL�SPECTIOP <br /> INSPECTION BY DATE INSPECTION BY . DATE i )7 _ <br /> . C t* <br /> E 1E 1426 Rev. 1--11, 1-74 2M <br /> H <br />