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. 77-„5';P_7/0 <br /> THIS PERMIT EXPIRES 1" YEAR FROM DATE ISSUED Date Issued -, J <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"9SlZe Avs�t-v ?i /M 4, end` tPd,CENSUS TRACT <br /> Owner's Name j,! Phone,aat <br /> Address 1�LU P e-fe v-e7- fes{ City IV,417e" <br /> Contractor's Name lj IV eA • �'License #°�� Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /Z;Z- 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 <br /> A 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 1.�iy6� � �, _ /)j4,�� Jr- A.-e <br /> Type of Pump �/'v r? h_rI— H.P. 'O <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done Pe ,dekW <br /> RES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure T <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distric t <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 <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 FINAL INSPECTION. l <br /> SIGNED TITLE <br /> rte .sw-, <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �_ DATE <br /> ADDITIONAL COMMENTS: ---r <br /> PHASE II GROUT INSPECTION P sg 4IRINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYPV <br /> E H 1426 Rev. 1-74 1177 2M <br />