Laserfiche WebLink
G SAN JOAQUIN �OC;AL HEALTH DISTRICT <br /> FOR OFFICE USE: ii 1601 E. -Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76'-)a44,1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 16-7� <br /> : � (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Hcalth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance.with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> + JOB ADDRE55/LOCATIONAd- � (� - � CENSUS TRACT <br /> 0 � <br /> "Owner's Name ---_ -_-y0p_( .�CG[Q�?? .. „.... Phone <br /> Address /7r.s � .,.. .....•........ City <br /> 1� - <br /> Contractor's NameUILL'oMam�,/:?4" ; License # /}y/3 Phone � � <br /> -- - <br /> TYPE OF WORK (Check): NEW WELL/Tr DEEPEN -/-7 RECONDITION/7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /7 Pump REPLACEMENT / <br /> Other / / . . . . . . <br /> DISTANCE TO NEAREST: SEPTIC TANK t — : SEWER LINES .. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER qM'6#r0M <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 /a // ti <br /> Domestic/private Drilled Dia. of Well Casing 1919, <br /> Domestic/public Driven 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 - Surface Seal Installed B <br /> PUMP INSTALLATION: <br /> . Contractor - <br /> Type <br /> ontractorType of Pump <br /> H.P. <br /> PUMP REPLACEMENT: Statex Work Done <br /> �. PUMP-'.REPAIR: i/ 1—State Work Done _ <br /> S DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> j Describe Material and Procedure <br /> � <br /> I hereby agree to comply with all laws and regulations of the Sar: Joaquin Local Health District <br /> anal the State of California pertaining to or regulating .well '•construction. Within FIFTEEN DAYS <br /> I-after completion of my-11work 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 toIIthe-best of. my..knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TOG UTING AND iNAL I PELT ON. <br /> SIGNED i TITL <br /> IE' (DLkff PLOT PLAN ON RPERSE SI E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY _ �' DATE 11.2- <br /> ADDITIONAL <br /> ZADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTIO PHASE III FINAL INSPECTION <br /> INSPECTION BY 57'r'-f. DATE ;INSPECTION BY DATE <br /> E H 1426 Rev _2M <br /> . i-7�. s <br /> ►/_?5 . <br />