Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _-POR"OFFICE USE: C/. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _ z^ <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 �in Rd.:- Stockton CENSUS TRACT <br /> Owner's Name Aaron De'f nc _n .i_ Phone 931_p()33 <br /> Address 2qq7 N._ Aj,jj ,74A grj, City tnckton <br /> Contractor's Name WP1 :Pr C4 Nnnnk License # 2n07,g4 Phone 94R RR17 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR PUMP 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 /> w. Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> XX 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, Walter G. Noack <br /> Type of Pump H.P. 30 <br /> PUMP REPLACEMENT: / / 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 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 GROUTING AND A FINU INSPECTION. <br /> SIGNED > a TITLE <br /> DRAW Pt T PLAN ON REVERSE SIDE)17 ( <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 4 <br /> APPLICATION ACCEPTED BY �' <br /> DATE -1 <br /> ADDITIONAL COMMENTS: ; �a <br /> PHASE II GROUT INSPECTION P- %i�F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �o <br /> E H 1426 Rev. 1-74 3/76 2M <br />