Laserfiche WebLink
r *• <br /> f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR"OFFICE. USE:- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781. <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �IP�3��d <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 3-6-70""'-6-7U <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 the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � . gq, g C NSUS TRACT <br /> k Owner's Name ' Phone <br /> Address � Fvu LC` (<ZvGC.� CityCP <br /> Contractor's Name License 111- �' 1 Phgne }�r� <br />: TYPE OF WORK Check) : NEW WELL _ _ s <br /> ( �EEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br />. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,= PIT PRIVY i <br /> F <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ; a9 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 'Q <br /> INTENDED USE TYPE OF WELL 1 CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool !Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing y ; <br /> r Domestic/public Driven Gauge of Casing <br />; irrigation =.= Gravel Pack Depth of Grout Seal 69 <br /> oc <br /> f Cathodic Protection Rotary Type of Grout <br /> Disposal Other 0%. Other Information <br /> �. Geophysical rSurface Seal Installed_ By: <br /> PUMP INSTALLATION: Contractor <br /> i Type of Pump H.Pl,.- <br /> PUMP REPLACEMENT:- / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> t <br /> DESTRUCTION OF WELZ: Well Diameter ' Approximiti Depth <br /> Describe Material and ..Pr:ocedure <br /> I hereby agree to comply with-all laws and regulations of the San Joaquin Local Health-Dis`t.ict <br />' and the State of California pertaining to or regulating well construction. Within: FIFTEW DAY51 . ' <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 iA true to theof my knowledge and belief. I WILL C L FOR A GROUT INSPECTION <br /> PRIOR TO RROIMNP AND_A - �VINISOECTLON. <br />' SIGNED TITLE ' <br /> (D W PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE. <br /> ADDITIONAL COMMENTS: !. <br /> PHASE II GROUT INSPECTION PHASE III/FINA-L INSPECTION r� <br /> INSPECTION BY DATE INSPECTION BY .�` .eDATE 6-12 <br /> E H 1426 Rev. 1-74 1/77 ; 2m <br />