Laserfiche WebLink
lam: 46 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOTO OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' n Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONS'T'RUCTION OR PUMP PERMIT Permit No. "7 7-�3�Ap <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-11- 7 <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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -- -A?/ , `� ✓r- CENSUS TRACT <br /> Owner's Name P�., . - , �r � � Phone <br /> Address _ „ n —_ city '"� <br /> Contractor's Name License # 6±3-2 i,�'Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /- _ <br /> PUMP INSTALLATION / / PUMP REPAIR /lf/ PUMP REPLACEMENT <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 V <br /> k' Irrigation Gravel Pack Depth of Grout Seal r\•� <br /> Cathodic Protection Rotary Type of Grout 1 <br /> Disposal Other Other Information u ! <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /-7 State Work Done - a <br /> PUMP REPAIR: State Work Done 4s r <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 knowle ge and be ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION ` <br /> SIGNED aJ TLE . <br /> RAW P)L61 P)01PLAS ON RECD SE SIDE) <br /> PHASE I <br /> F DEPARTMENT USE ONLY <br /> , <br /> APPLICATION ACCEPTED BY � DATE s <br /> ADDITIONAL COMMENTS: ,{ <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7 ' <br /> E H 1426 Rev. 1-74 3/76 ?�I <br />