Laserfiche WebLink
Y4 SAN JOA UIN LOCAL HEALTH DISTRICT <br /> . Q <br /> FO—FOUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7--L <br /> -/D <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued2-2,y-76 <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. Joaquii <br /> County Ordinance No.. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � , ,� , / 4ua CENSUS TRACT <br /> Owner's NameS_Ca jgP 4 Phone 9Z1 IS)-5- <br /> Address <br /> SSAddress �' A �, A"I �"�"— City h� <br /> Contractor's Name License # Phone /� '(� 5 <br /> TYPE OF WORK (Check): NEW WELL/ `T DEEPEN /-' RECONDITION /-7 DESTRUCTION /—j <br /> PUMP INSTALLATION / / PUMP REPAIR /0'-PUMP REPLACEMENT /7 <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 /> 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 H.P. <br /> PUMP REPLACEMENT: , / j State Work Done <br /> _UMP ,REPAIR: / / State Work Done � 17 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth R\ <br /> Describe Material and Procedure \yy <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 y� e 2� TITLEalyL�� A � <br /> —Dfell- <br /> RAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 2/X <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE- jIj!/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />