Laserfiche WebLink
l� SAN JOAQUIN L =A.aLTH. DISTRICT <br /> FOE OFFICE USE: V, 1601 E. Hazelton A- , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' Date Issued U <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 g'jC7 A., )R4A CENSUS TRACT <br /> Owner's Name _ L:�� �/ LWA!RQ ---- Phone Fj alir <br /> —r <br /> Address City .Sc�•c�_ <br /> Contractor's Name T 0. 96e �.- �S License # o2 79b/b Phone <br /> i <br /> TYPE OF WORK (Check) : NEW, WELL / DEEPEN. /� RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION IT/ PUMP REPAIR/ / PUMP REPLACEMENT L <br /> I 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 �1 <br /> Domestic/private Drilled Dia, of Well Gaging <br /> Domestic/publi.cDriven Gauge' of Casing <br /> Irrigation _ Gravel Pack Depth of GroutSeal <br /> 4 Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> ti, �1r.J f <br />` PUMP INSTALLATION: Contractor n.% <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP .REPAIR: / / State Work Done., <br /> DESTRUCTION OF, WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to c6mpl3r'"with all la!is end regulations of the San Joaquin Local Health District <br /> andtithe'kState- of.kCalifornia-pertaining.-tv,or, .regulating well"construction. wram 'FIFTEEN DAYS <br />` after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 TO GPQUTING AND h FIN INSPECTION. <br /> SIGNED TITLE <br /> DRAW P ; T PLAN 'ON REVERSE SI------------ <br /> DE ' ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> j PHASE II GROUT INS CTION PHAWI1 I INSPECTI N <br /> I INSPECTION BY DATE INSPECTION BY ATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br /> ,. <br />