Laserfiche WebLink
/j'/1g SAN JOAQUI14 LOCAL HEALTH.DISTRICT <br /> FOR OFFICE USE: t1 1601 E. Hat-elton Ave. , Stockton, Calif. <br /> Telephone:. (209) 466-6781 <br /> APPLICATION 'FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EMPIRES 1 YEAR FROM DATE ISSUED Date Issued J_ _ <br /> 3 (Complete In TriplicateX <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 CENSUS TRACT <br /> Owner's Name CA tt �a n 6,1 <br /> - Phone <br /> Address City <br /> Contractor's Na License #`jV-3?ArPhone 1192, - 4?c <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /_T RECONDITION /_ DESTRUCTION /7 <br /> PUMP INSTALLATION _ PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other Ll <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 /> 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 INSTALLATI69: contractor <br /> Type of Pump H.P.- G <br /> PUMP State Work Done <br /> PUMP .REPAIR: . / / State,Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agreetocomply 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 thembeforeputting -the-well in use. The above <br /> information is true to the,best of my-Jcuowledge belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FINAL INSPECT ON. <br /> SIGNED - TITLE . " <br /> ON SE.S"IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �3/?-77 <br /> 3/76 ZM <br /> H 1426 Rev. 1-74 <br />