Laserfiche WebLink
ACis SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR F C <br /> OFE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ' APPLIC91ION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 59� <br /> «;�, THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued I- <br /> 3 �""GC-k� (Complete In Triplicate) <br /> Application s 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 />{ �, a <br /> JOB ADDRESS/LOCATION- _ � 77 56/4) � /�. - Ile CENSUS TRACT- -- . <br /> Owner's Name o f oil ►, Phone <br /> i � -- <br /> Address !b t deI 4 City C <br /> License # l Phone r?� �► <br /> Contractor's Name J <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN RECONDITION PRECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT <br /> Other <br /> I <br /> f 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 i CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> l Domestic/private Drilled Dia, of Well Casing \ <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 By: <br /> k PUMP INSTALLATION: Contractor C� ) <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> e. <br /> PUMP .REPAIR: / / State. Work Done ;Z,0( Z0- 11 /4� 0 ,/ <br /> DESTRUCTION OF WELL: Well Diameter . Approximate Depth <br /> Describe Material and Procedure - <br /> I hereby agree to comply with all laws and regulations of the;Sran"Joaquin Local Health District <br /> i and the State of California pertaining to' or regulating well"'.c'onstruction. 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. istrue to the-best--of my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL Pr,CT N, <br /> SIGNED TITLE �1' <br /> ® � P T' PLAN `0 FRSE SIDE) _ I; <br /> OR DEPARTMENT USE ONLY <br /> PHASE I F <br /> APPLICATION-ACCEPTED BY DATE <br /> F ADDITIONAL COMMENTS: <br /> PHASE II T NSP CTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 0-/.j''TZ <br /> - .• • . 3/76 2M <br /> i E H 1426 Rev. 1-74 <br />