Laserfiche WebLink
�v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 6- q9,,k <br /> Telephone: (209) 466-6781. 7 ?h 6�9 p � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 8--a-26 ' <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. <br /> This <br /> application <br /> is the San�Joaquin Localcompliance <br /> Health San <br /> DistrictJoaquin <br /> Rulesand <br /> County Ordinance No. 1862 and the Regulations <br /> JOB ADDRESS/LOCATION O 32S CENSUS TRACT '_ <br /> Phone <br /> Owner's Name <br /> Address !C City _"Z�j� - <br /> License # Phone ' <br /> Contractor's Name -" <br /> i <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN / / RECONDITION /�T DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR'/ / PUMP REPLACEMENTI_T <br /> Other J-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 7d SEWER LINES PTT PRIVY — <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT IC WELL <br /> OTHER <br /> F PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION DOMEST <br /> SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL � <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing r <br /> Domestic/public Driven Gauge of Casing `}U <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 B : <br /> PUMP INSTALLATION: Contractor dq <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> f PUMP .REPAIR: / / State Work Done <br /> f � A proximate Depth <br /> DES-TRUCTION OF WELL: Well Diameter - <br /> Describe Material and Procedure <br /> r <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 /> f 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 TOROUTI D A FIJiAL INSPECTION. <br /> ' SIGNEDTITLE 44 <br /> D W P PLAN -ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> i PHASE I i0 DATE <br /> APPLICATION ACCEPTED BY (/ <br /> ADDITIONAL COMMENTS: <br /> WPHAS /FAL INSPECTTPHASE II GROUT INSPECTIONATE <br /> INSPECTION BY DATE INSPECTION B <br /> 3/76 2M <br /> v u I L9A = vatic- 1-74 <br />