Laserfiche WebLink
_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .i OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-447 p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name -_- C. t Phone <br /> Address - -s �7 Ci [ s �`. cityr L <br /> Contractor's Name License # x11-hone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION/-7 PUMP REPAIR/-Y7 PUMP REPLACEMENT /7 <br /> Other /-7 <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 /> X _ 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 INSTALLATION: Contractor -. <br /> Type of Pump A.P. 0 <br /> PUMP REPLACEMENT: . Ll State Work Done <br /> PUMP ,.REPAIR: T State Work Done c . <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 . myw g nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL IN E&I . <br /> SIGNED . TLE . <br /> WPLOT PLAN -0-N-j7tVFaSE SIDE <br /> PHASE T FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By DATE 6 •2S'" <br /> ADDITIONAL COMMENTS: <br /> PHASE II G UT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE I1?ar, <br /> E H 1426 Rev. 1-74 2M <br />