Laserfiche WebLink
y °�w <br /> ._ SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedJAN 11 1978 <br /> (Complete In Triplicate) <br /> Application is $ereby 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 32— 0 3 IV IO�I XV-3 '6 /CENSUS TRACT <br /> Owner's Name Dei Auch Phone <br /> Address [ city '~ <br /> Contractor's Name tAelln S ( ( r� License # Phone 5SL '_f f <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTZLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> C� <br /> Other / / _ rj <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 ! t " <br /> Domestic/private ^ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 510 <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other Other Information :51 a b an Q„C• _ <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR- / / State Work Done <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 the well and notify them before putting the well in use. The above <br /> information i u t the be t m knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G A L S I <br /> SIGNED ZTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DE ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE AM <br /> ADDITIONAL COMMENTS: <br /> PHMEIII G OUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE � INSPECTION BY DATE J� <br /> E H 1426 Rev. 1-74 -- <br />