Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTHH DISTRICT <br /> F0r,_ OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?�-9/9 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued -a3 76 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct i <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rule IV <br /> and Regulations of th n Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION' � CENSUS TRACT <br /> Owner's Name Phone.42 <br /> _ <br /> Address G� k City ` <br /> rr p ,� <br /> Contractor's Name �� -� �� License X0,46 Phone '4 -^r <br /> �A <br /> i <br /> TYPE OF WORK (Check) : NEW •WELL / / DEEPEN %/ RECONDITION /_/ DESTRUCTION /X-7 E'l <br /> PUMP INSTALLAT / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Ofher <br /> DISTANCE TO NEAREST: SEPTIC TANK F-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-,, `1 Dia. of .Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing i <br /> d <br /> Domestic/public Driven Gauge of Casing I <br /> Irrigation ��_ .q,a.. Gravel Pack'-. 'Depth of .Grout Seal 4 <br /> Cathodic Protection Rotary Type' of �Grout <br /> Disposal } Other-- -W ' Othei Information <br /> Geophysical : "x �F. Surface 'Seal Installed B : <br /> r <br /> PUMP INSTALLATION: Contractor �� 44_ -a <br /> Type of Pump W k H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> — i <br /> DES-TRUCTION 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 anew well, I`wiTl'fui^ciish the-San-Joaquin Lo-cal-Health-District a <br /> WELL DRILLERS-REPORT-of. -the-well-and notify them.before. putting the=-wel in' use. " Tl e above <br /> information is true t he best of my knowledge and belief. I WILL C FOR A GROUT INSPECTION <br /> PRIOR TO G UTING D A FINAL INSPECTIO <br /> SIGNED ,%fir TITLE <br /> DRAW PI T PLAN 'ON REVERSE SIDE) <br /> FOR D PAR NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY UDATE '/ -7- <br /> ADDITIONAL COMMENTS: W i <br /> PHASE II GROUT INSPECTION PMSMX/FINA INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _ //-77 <br /> • f a� , �,,,��L- �� .�� - �° per <br /> E H 1426 Rev. 1-74 f�i3il/oorr �Y o c-1� . 376 2M <br />