Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F09;'OFFICE USE: 1601 E. Hazelton Ave.. , Stockton, Calif. <br /> Telephone: (209) 466-5781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMA''PERMIT Permit No. <br /> -V-p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 11-le-2,4 <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 Joaquinj <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> s- <br /> .TOB ADDRESS/LQCATTQN ,. _ ~• CENSUS TRACT <br /> . f <br /> Owner's Name �, f v t - Phone , <br /> Address City p <br /> Contractors Name : License / 2 Phone .5 <br /> TYPE OF WORK (Check) : NEW WELL/;R"- DEEPEN /7 RECONDITION /7DESTRUCTION /-7 <br /> PUMP INSTALLATION /C/-SPUME' REPAIR -7 PUMP REPLACEMENT f7 <br /> Other <br /> DISTANCE •TO NEAREST: SEPTIC TANK f SEWER LINES PIT PRIVY ' <br /> S`' <SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE-PIT OTHER <br /> \J ,1 PROPERTY LINE - PRIVATE DOMESTIC WELL_' PUBLIC_DOMESTIC .WELL e. ^ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. c --Cable Tool Dia. of Well Excavation <br /> Domestic/ ivat�e Drilled Dia. of-WellCasing X13 <br /> Domestic/pub - .Driven Gauge of-.-Casingl7 1 �j <br /> Irrigation Gravel Pack Depth 6-f-Grout -Seal _ �.' <br /> :Cathodic Protection Rotary }. Type. of Grout ° "' 1 <br /> Disposal Other- 'Other Information , I.j 7 <br /> Geophysical ^-^r'Si r'face Seal.-Installed,;B�:, <br /> PUMP INSTALLATION: Contractor .i "x ` �'"; •� ; v�f` <br /> Type of Pump ,' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR. / / State Work Donee , <br /> t <br /> PE&TRUCTION OF WELL: Well Diameter Approximate Depth t ; <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 furhish 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 j <br /> information is true to the-best-of my-knowledge and beiief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTJJON. <br /> SIGNER TITLE G' 4 <br /> (DRAW PLOT PLAN ON REVERSE SIDE - - - i <br /> FOR DEPARTMENT USE ONLY' ^ <br /> PHASE I <br /> APPLICATION ACCEPTED BY "� DATE ' <br /> ADDITIONAL COMMENTS: U <br /> PHA GROUT 'INSPECTION' -P E III FIN -INSPECTION'- <br /> J INSPECTION BY DATE 77c/' >-7G INSPECTION BY `` ATE <br /> E H'1426 Rev. 1-74 4/75 2M ;� <br />