Laserfiche WebLink
SAN JOAQUIN LaCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave:,- Stockton, Calif. <br /> Telephone: (209) .4466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 716 <br /> 4, <br /> 76 - y,� <br /> THIS .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 "f-IVA OR F o CENSUS TRACT <br /> k <br /> Owner.'s Name ,�' $'G N?�/ _ - - PhonealSOCZEW <br /> F Address 70 0 ORE olLCity S 7/C�/Y �',QL/,r <br /> Contractor's Name G . D S'� f,U�� LL 6' License #2 a Phone 74-$'_?p 2 ,r/ <br /> TYPE OF WORK (Check) : NEW.WELL X/ DEEPEN /% RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR/ / 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 --�-=CONS-T-RUCTION SPECIFICATIONS \ <br /> j Industrial �, Cable Tool Dia, of Well Excavation />_1 V <br /> _E_ Domestic/private Drilled Dia ,of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Taj <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other _Y Other-Inforination' <br /> Geophysical Surface Seal Installed By_: <br /> PUMP INSTALLATION: Contractors�Os li l <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: - / / State Work Done <br /> PUMP .REPAIR: J / State Work-Done <br /> DES,T_RUCTION OF WELL: Well Diameter Approximate Depth <br /> C � Describe Material and Procedure <br /> fM <br /> I he 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 /> i 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 TITLE �_ <br /> D PL PLAN ON REMSE SIDE)rt <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,. - <br /> APPLICATION ACCE D <br /> ADDITIONAL COMMEN . <br /> 14 <br /> PHA JO;U4TINSPECTION PHAS INSPECTION <br /> INSPECTION BY DATE, p- INSPECTION BY DATE <br /> E H.1426 Re/Z4 <br /> 3/76 2M <br />