Laserfiche WebLink
r -- <br /> -�� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USf-- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 27_U� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-13-72 <br /> F (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 /> t County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin .Local Health District. <br /> JOB ADDRESS/LOCA - '6 <br /> ` - ' CENSUS TRACT <br /> Sr�7 <br /> Owner's;Name :-- <br /> `�- S23/Phone <br /> Address <br /> CityC�� <br /> r.. <br /> Contractor's Name �v '�' �t; `—fie ;a : < License " <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN ',;RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT`, <br /> Other E7 <br /> • it <br />' DISTANCE TO NEAREST: SEPTIC TANKSEWER 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 n� <br /> Domestic/private Drilled ? Dia. of Well Casing <br /> Domestic/public Dri�reu ! Gauge of Casing <br /> Irrigation Gravel-Pack, ! Depth of Grout Seal <br /> Cathodic Protection Rotary . Type of Grout <br /> Disposal Other' Other Information <br /> Geophysical t - 'Surface Seal Installed B _ <br /> PUMP INSTALLATION: Contractor — <br /> Type of Pump— <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 'PUMP REPAIR: <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth t <br /> Describe Material and Procedure <br /> I hereby- agree to •comply)with- all• laws-and regulations-ofthe -San Joaquin Local Health District f <br /> and the State.~of -California pertaining, tc re ulatin <br /> � g .g,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- my knowledge'. and belief. I WILL tL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTINGAN PA FINAL INSPECTION. ; <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) -� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,. DATE 7 7 <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION t PHASE /FINAL INSPECTION <br /> INSPECTION BY DATE J F INSPECTION BYSATE '• 7 7 <br /> t <br /> E H14 ' ' <br /> -- 26Rev. 1-74 � y , � 1 177 _ • 2M <br />