Laserfiche WebLink
# 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. L3 ild <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued z'-/a'49 <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 ��iGj/ �L�,� L/�7 CENSUS TRACT <br /> Owner's Name A-7k Phone <br /> Address 0ity <br /> Contractor's Name �(,c�v r Lk nse # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/% '-RECONDITION / / DESTRUCTION L- <br /> PUMP-INSTALI.ATION-/ /'---PUMP-REPAIR-/-// -PUMP-REPLACEMENT /_7Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ll <br /> Industrial Cable Tool Dia •o.fsWell Excavation # <br /> Domestic/private I Drilled. Dia..-of-Well Casing <br /> Domestic/public Driven .Gau_g.e of Casing <br /> Irrigation f -rGravel Pack Depth of .Grout Seal <br /> Cathodic Protection 1 Rotary Type /'rout <br /> Disposal I/ Other Other,/Information <br /> Geophysics.]_ f Surface Seal__Installed By: f' <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump f 1 H­.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> FO N <br /> PUMP�REP.AIR_ . ' /HState Work Done 1 ('€ ,. (. , j✓ J <br /> DESTRUCTION OF WELL: ell` Diameter s pp.oximate.%Depth 5�(� <br /> I escribe Material and rocedure A <br /> I hereby agree to .comply with a 1 laws and regal tions 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 wi-ll-furnish-the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them }before putting the well in use. 1 The above <br /> information is true to the!best of. my-knbwled'g 'evand ibe1ief. I;WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL! INSPECTION. t 1 , <br /> 1. <br /> SIGNED /U v I 1 ._� TITLE <br /> ' t (DRAW PLT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: LZ <br /> PHASE II GROUT -NSPECTION PHASE-,;�U./FINALyANSPECTION <br /> INSPECTION BY' AZZ { .-INSPECTION BY ATE <br />.. E H 1426, Rev. 1-74 ��" <br /> 3/76 2P <br />