76-822 - Laserfiche WebLink

Home Browse Search

Esy* � SAN JOAQUIN LOCAL HEALTH DISTRICT FOR OFFME USE: 1601 E. Hazelton Ave. , Stockton, Calif. Telephone : (209) 466-6781. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. THIS- PERMIT E)CMES. 1 YEAR FROM DATE ISSUED Date Issued (Complete In Triplicate) Application is hereby made to the-San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San. Joaquin Local Health District. JOB ADDRESS/LOCATION7h�,�r��.o�e _ _ _ • _ _ CENSUS TRACT V— Owner's Name Phone Address 40 N 2 City Jto/ro,h l Contractor's Name cam-•- License # / ,tom Phone 2 -71,7e, r i TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ y RECONDITION / / DESTRUCTION /_7 PUMP INSTALLATION / / PUMP REPAIR IVI PUMP REPLACEMENT /_7 Other DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Industrial Cable Tool Dia. of Well Excavation Domestic/private Drilled Dia. of Well Casing Domestic/public Driven Gauge of Casing Irrigation r r =. Gravel Pack- Depth of Grout Seal Cathodic Protection' Rotary Type of Grout µ IN Disposal Other. Other Information ' 1 Geophysical 4 Surface Seal Installed By_:_- PUMP INSTALLATION; Contractor '� TYPe of Pump ,.._ 7, lotG-9 �CF H.P. Y PUMP REPLACEMENT / / State Work Done PUMP .REPAIR: / State Work Done pCd11J11 1142T DESTRUCTION OF WELL Well Diameter Approximate Depth Describe Material and Procedure I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District and the State of California pertaining to or regulating well•construction. Within FIFTEEN DAYS after completion of my work on a new well, I will furnish the San Joaquin Local. Health District a WELL DRILLERS REPORT of the well and notify them before putting the .well in- use. The above information is true to the-best of my. knowled.g -and belief. I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INS N SIGNED TITLE ( PLAN ON FRSE SIDE)— FOR DEPARTMENT USE ONLY { PHASE I APPLICATION ACCEPTED BY ULA DATE _ 9 -3-7G ^� ADDITIONAL COMMENTS: PHASE II OUT INSPECTION PHASE III/FINAL INSPECTION INSPECTION BY.— W DATE INSPECTION BY DATE' 2/3 -'7� 3/76 E Ha 1426 Rev. 1-74;