Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)'466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-2,glLd <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , /7?Z <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> acid/or install the work herein described. This application is made in compliance with San Joaquii <br /> County Ordinance No. 1862 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION W CENSUS TRACT <br /> Owner's Name l°S° /pQ7f Phone <br /> Address City C/ <br /> Contractor's Name� zz0 License iW®,/&05-Phone T <br /> TYPE OF WORK (Check) : NEW WELL . DEEPEN /_/ RECONDITION /_7 DESTRUCTION /) <br /> PUMP. INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /) <br /> Other <br /> 4 DISTANCE TO NEAREST: EPTIC TANK- SEWER LINES PIT PRIVY <br /> i fp�74SE SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT /S-O OTHER <br /> p {f PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> k INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS' <br /> # Industrial Cable Tool Dia. of Wel1;,Excavation <br /> y Domestic/private Drilled Dia, of Well Casing G <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ;Gravel Pack "Depth of Grout-Seal - <br /> Cathodic Protection 'Rotary Type of Grout .;-7 v <br /> Disposal Other �_ '' .Other Information ; e <br /> Geophysical .' Surface Seal Installed BY: p <br /> PUMP INSTALLATION; Contractor ,. <br /> Type of Pump H.P. q <br /> ` O <br /> -PUMP REPLACEMENT: / / State Work Done <br /> F PUMP -REPAIR: / / State Work Done <br /> Il DESTRUCTION OF WELL: Well .D ia meter _ � .. Approximate Depth <br /> + Describe Material and Procedure <br /> I hereby agree to comply/with all Yaws 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 is true /to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UTING 4U- A FINAL I SPECTION. <br /> SIGNED / _ TITLE <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> C APPLICATION ACCEPTED BY 4 DATE �LIZ <br /> 7 <br /> ADDITIONAL COMMENTS: <br /> PHAS9 II GROUT INSPECTION7— .. ""'�'" "PHASE' II FINAL INSPECTIOJX <br /> INSPECTION BY i_ - `DATE - INSPECTION BY t 7 7?7 - TE `- <br /> E H 1426 Rau. 1-7L. <br />