Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) . 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 76� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6- <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 /> l Ci - �� y ` <br /> JOB ADDRESS/LOCATION � � � � -_ �� ��-�%�� ��� CENSUS TRACT <br /> 5 ,r <br /> Owner's NamePhone <br /> Address _ L j_ / Ali 7- 4f 1 L_ A & City <br /> Contractor's 'Name 1 1 A-j, `-TI �E� 1�r� ����� License Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION f-1 DESTRUCTION /-7 <br /> PUMP INSTALLATION /0( PUMP REPAIR / / PUMP REPLACEMENT /-J <br /> Other /-7 <br /> bISTANCE TO NEAREST: SEPTIC TANK <br /> )o , SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROkRTY 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 f '' <br /> Domestic/public Driven Gauge of Casing <br /> - <br /> Irrigatien 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 <br /> PUMP .REPAIR: F/ 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 /> acid 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 INSPE ON <br /> PRIOR TO GROUTING .AND A FINAL INSPECTION. . <br /> SIGNED '- TITLE6r <br /> T AN ON REVERSE SIDE <br /> PHASE I ' <br /> 6� r DEPARTMENT USE ONLY <br /> J , <br /> APPLICATION ACCE-PT--R-n NOR6ARDATE �� -7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION"BAY �-�� DATE L-, G INSPECTION BY DATE - <br /> IL E H 1426 Rev. 1-74 3/76 <br />