Laserfiche WebLink
1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-('OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 .6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74- K 6 3 W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 9-1- 7 <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 CENSUS TRACT <br /> Owner's Name Phone 46 6 " 7--7- '7 <br /> :Addresses 7 �1. �� a S City . <br /> Contractor's Name .y� , � License # Phone <br /> TYPE OF WORK (Check): NEW WELL /-" DEEPEN RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / UMP REPAIR /-7—pump REPLACEMENT f7 <br /> Other / / — — — <br /> 'DISTANC O N ST: -SEPTIC TANK U SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD , O f MEPAGE PIT Z OTHER <br /> 2- r�v PROPERTY LINE - PRIVATE DOMESTIPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 1 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: Ll State Work Done <br /> PUMP REPAIR: L� State Work Done f <br /> RE&TRUCTION 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 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 2E2UTING AND A FINAL INSPECTION. <br /> SIGNED a � TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY E DATE 7-27 -7�_ <br /> 1 E H 1426 Rev. 1-74 1. 74 2M <br />