Laserfiche WebLink
SAN JOAQUIN -LOCAL HEALTH DISTRICT <br /> FOErOFFICE USE. 1601 L. Hazelton Ave. , Stockton, Califs _ <br /> Telephones (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 ;7/3p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 1-76a7 S. _ C. CENSUS TRACT <br /> Owner v s Name —�C 2KA1 C -P ,., 1. r, ig . Phone 9--2277 <br /> 0 <br /> Address .Arr+ -�• City cS Gu <br /> Contractor's Name j,p, Isug". Sd•J . License # 3t,Va Phone CsM =�Lv <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN -/-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR 1-7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER 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 <br /> Domestic/private Drilled Dia. of Well Casing ` <br /> Domestic/public 1 Driven Gauge of Casing t� <br /> Irrigation Gravel Pack Depth of Grout Seal v <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ' Other Other Information <br /> Geophysical' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done &t2L' ue S LL <br /> PUMP :REPAIR: /-7 State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter y Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sart 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 beGROUT INSPECTION <br /> PRIOR TO GROUUVG AND FI INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY DATE - T ' <br /> ADDITIONAL COMMENTS: . <br /> PRA S GROUT INSPECTION PRASE II/ NAL INSPECTION <br /> INSPECTION BY . DATE INSPECTION BY DATE <br /> i E H 1426 Rev. 1-74 <br /> 1-74 2M <br />