Laserfiche WebLink
iI <br /> V�; 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. 77-3 <br />` THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /6 a-77 <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 workherein 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 /6 d2 CENSUS TRACT <br /> 3 <br /> Phone cs[r <br /> Owner's Name. <br /> , <br /> City <br /> r Address r <br /> Contractor's Name <br /> License 4 � �'Phone 1a <br /> ' _ � DESTRUCTION � -- <br /> TYPE OF WORK (Check) : 'NEW WELL/_T DEEPEN / / RECONDITION / <br /> / / _ /� <br /> ' PUMP INSTALLATION/ / PUMP REPAIR I / PUMP REPLACEMENT !L� <br /> i <br /> Other <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ ._. Y CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY EINE -- PRIVATE DOMESTIC WELLi PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ,, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> T?� Domestic/private Drilled Dia.�-of Well Casing <br /> Domestic/public Driven r Gauge of Casing <br /> Irrigation Gravel Pack Depth of,Grout Seal <br /> A Cathodic Protection Rotary y.. - Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical , F Surf ac Seal Installed B <br /> t PUMP INSTALLATION: Contractor <br /> Type of Pump �.'. H.P. <br /> / <br /> PUMP REPLACEMENT: State Work Done <br /> E PUMP .REPAIR: / / State Work Done <br /> I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i' 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 vn 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 ANDJRAL INSPECTIO <br /> SIGNED /' TITLE <br /> DRAW Pt T' PLAN' ON REVERSE SIDE) �: <br /> FOR DEPARTMENT USE ONLY <br /> t PHASE I <br /> APPLICATION ACCEPTED BY DATE -7 <br /> ADDITIONAL COMMENTS. °IN <br /> PHASE IIGGROUT INSPECTIO P I/FI AL INSPECTION <br /> k INSPECTION BY IiM DATE <br /> INSPECTION B DATE <br /> 3/76 2M <br /> E H 1426 Rev. -1 h.74 Y <br />