Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE.OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209),466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 �o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -,ISSUED. Date Issued, _���� <br /> (Complete In. Triplicate) , <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application 'ie made in compliance with San Joaquina <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Jaaquin Local Health District. <br /> JOBABBIMOBAOCATION ��'LJW1 10714tt + CENSUS. TRACT.. <br /> Owner's Name014Phone ' <br /> Address / acity w <br /> ' <br /> Contractors Name d• /- �1.0 <br /> - � License �p����Phone <br /> TYPE OF WORK (Check); NEW WELL '/ DEEPEN '/7 RECONDITION 1=T DESTRUCTION /7 <br /> PUMP INST LATION A3 PUMP REPAIR •/7 PUMP REPLACEmENT /7 <br /> Other /_7 T . . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOAL FIELD 08"P@ft/SEEPAGE PIY7 <br /> rOTHER <br /> PROPERTY LIN RIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. <br /> Industrial Cable Tool Dia. of Well Excavation L � <br /> Domestic/private Drilled Dia. of Well Casing 'Cy <br /> Domestic/public Driven Gauge of Casing r/ a <br /> Irrigation Gravel Pack Depth of Grout-Seal. 1 <br /> Cathodic Protection Rotary Type of Grout . <br /> 1 <br /> Disposal. Other Other Information <br /> Geophysical Surface Seal Installed B : . . . <br /> PUMP INSTALLATION: Contractor Lafinc A4MA -S L00,14 <br /> Type .of Pump .E H.P. <br /> PUMP REPLACEMENT / / State Work Donee <br /> PUMP ,REPAIR: /7 State Work Done <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 we11 '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•be'st -of my-knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION <br /> SIGNED <br /> ( P ON REVERSE SIDE <br /> FOR/DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY2 DATE ' .1,112/_7C <br /> ADDITIONAL COMMENTS: 7. r <br /> PHASE II GROUT I CTI PHASE IIIIFINAL INSPECTION. <br /> INSPECTION BY DATE _, INSPECTION BY DATE 2 7 <br /> ;� '.�r��...,fir,� �-...•msµ:�ye.�"`e. """" - <br /> Y <br /> E H-1 26 <br /> - - Rev. 'R'1-74 ,� r _ .. --- - .h/?5- 2M- <br />