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 -1Q <br /> ./V,�Zt THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) f <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 ADDRANameN;,,,. <br /> fc-�� "-'"�-� CENSUS TRACT <br /> Owner's Phone/7 �—AddressCi ContractLicense J# %393 Phone4tgo/% Jif <br /> (TYPE OFWORK (Check) : NEW WELL /� DEEPEN / RECONDITION / / DESTRUCTION /'7 <br /> PUMP INSTALLATION /y/�PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT 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 SPECIFICAATJQNS <br /> :��Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing n, <br /> Irrigation 6ravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary * Type of Grout <br /> � }}" <br /> Disposal Other '' Other Information _ -- <br /> Geophysical rface Seal Installed By:__ <br /> 4 <br /> PUMP INSTALLATION; Contractor 7f € <br /> Type of Pump <br /> PUMP REPLACEMENT: Y` h /'y State Work Done -. <br /> PUMP :REPAIR:", - /, /_ ,.State,-Work--Dane <br /> DES•TRUCTION� OF WELL:L Well Diameter Approximate Depth ; <br /> Describe Material and Procedures <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION ' <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> flo ,A TITLE CW <br /> {DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION .ACCEPTED B DATE 7 i <br /> ADDITIONAL, COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHAS / INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �..ti.. DATE . gr <br /> E H 1426 Rev... 1-74 i X77 2M r <br />