Laserfiche WebLink
SAN .IOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE: X1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76- �17 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued e`z 3- 76 <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 Regula tio s of the Sa Joaquin Local Health District. <br /> JOB ADDRESS/LO ION CENSUS TRACT <br /> Owner's Name Phone /•- o <br /> Address ' r City <br /> Contractor's Na LLQ License //� 7Phone <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN / / RECONDITION / '/ DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR /f 7/ UMP REPLACEMENT /7 <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 Driven Gauge of Casing <br /> d' 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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Work Done �5XT'E/J P/ j>jF <br /> PUMP .REPAIR: / / State Work Done (° <br /> DES-TR76CTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws 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 TO GROUT AND A F I SPE <br /> SIGNED TITLE J <br /> (DMW PL TPLAN ON RE ERSE SIDE) ' <br /> F PARTMENT USE ONLY <br /> :RASE I <br /> PLICATION ACCE BIr Al -- DATE <br /> DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PH&H I FINAL IN PECTION <br /> SPECTION BY DATE INSPECTION B D E � 77 <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />