Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> :0aICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9SW <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 is made in compliance with San Joaquin <br /> f County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> -Owner's Name XV Orsi Phone 'F3 <br /> Address 2 C City 7C <br /> Contractor's Name` License # Phone �.,?;- <br /> TYPE OF WORK (Check): NEW WELL ' t7, DEEPEN '/7 RECONDITION /_7 DESTRUCTION 17 <br /> PUMP INSTALLATION/ / PUMP REPAIR '/ 7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /Q& SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> Domestic/private Drilled Dia. of Well Casing f`_v _ L:5 iG <br /> Domestic/public Driven Gauge of Casing _ I <br /> Irrigation Gravel Pack' Depth of Grout Seal " <br /> Cathodic Protec_t_ion ^ Rotary Type of Grout ' ok <br /> Disposal Other Other Information <br /> k Geophysical Surface Seal Installed B .p`-- <br /> PUMP INSTALLATION, Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <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 well"construction. Within FIFTEEN DAYS <br /> f 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 INSPECTION <br /> ' PRIOR-TO GR N D A MAL ION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE J' 2 ,' 17Z <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> A <br /> 4/75 <br /> . E 8 1426 Rev. 1-74 ,•^ 2N1 <br />