Laserfiche WebLink
�• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT •Permit No. <br /> - R T 7, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED *Date Issued 3_i$-7 <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 /> County Ordinance No. 1862 and the Rules and Regulations of�_tie San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a `. �.y,��oy CENSUS TRACT 003 •- asa-o12 <br /> Owner's Name Phone <br /> f � <br /> FAddress `/ Sr �,. ��y/lcQ.�- City <br /> J� _ - - <br /> Contractor's Name h1 License #/41373 Phone_20J <br /> TYPE OF WORK (Check) :. ..NEW WELL ,,& DEEPEN 'i7 RECONDITION / / DESTRUCTION /'7 <br /> 1PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> k <br /> Other, / / <br /> DISTANCE TO NEAREST: SEPTIC{TANK 75-1f SEWER LINES PIT PRIVY .J <br /> SEWAGE' DISPOSAL FIELD /ad CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC.WELL PUBLIC DOMESTIC WELL <br /> - INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS In <br /> � . <br /> Industrial } I Cable Tool -_ Dia. of Well Excavation foi, <br /> Domestic/private I Drilled ;Dia. of Well Casing 6' .." <br /> l Domestic/public Driven AGauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary,: F _ ,Type of Grout _ <br /> Disposal Other Other Information h <br /> Geophysical T t ;(Surface Seal Installed By: <br /> - t <br /> PUMP-INSTAL`LATION: ContraCtor""� "�')9'- _ <br /> Type of Pump H.P. j <br /> PUMP REPLACEMENT: / / State Work Done ; <br /> PUMP .REPAIR: / / State,Work Done = <br /> N_ <br /> a DESTRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> ,Describe Material and Procedure x. <br /> i J <br /> k 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 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 i true to the best of myknowledge and belief.. I WILL CALL FOR A GROUT INSPECTION v <br /> PRIOR TO GRO NG MD 4JOAL INSPE_C21ON. <br /> SIGNED TITLE <br /> RAW-POT PLAN ON REVERSE SIDE) V �—`�" <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY e• DATE - 92 <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II .GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 6 INSPECTION BY DATES <br /> y E H 1426 Rev. '1-74 .. � . <br /> 3/76 2M <br />