Laserfiche WebLink
I <br /> Ave /�FOR OF,FE E USE: AN JOAQUIN LOCAL HEALTH. DISTRICT <br /> 61 01 E. Hazelton Ave. , Stockton, Calif. <br /> � <br /> —' Telephone: (209) 466-6,781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �gip <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7� <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 i rIA, CENSUS TRACT <br /> Owner's Name v d+ R' d' -s° Phone <br /> Address -4F City <br /> Contractor s Name <br /> License # l 3 2N Phone Y-7674 <br /> II TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION RECONDITION / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR I)C/ PUMP REPLACEMENT f_T <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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation V <br /> < Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protettioh Rotary Type of'Grout <br /> Disposal Other Other Information <br /> Geophysical., Surface Seal Installed By: <br /> it <br /> I PUMP INSTALLATION: Contractor - <br /> Type of Pump H.P. — <br /> I <br /> PUMP REPLACEMENT: f ./ State Work Done <br /> PUMP .REPAIR: / '/ State Work Done <br /> DESTRUCTION OF WELL: We11 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 ofmy 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 . ow e-d-ge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T ROU INC MD A F I,N_SP I <br /> SIGNED . r TITLE <br /> �� _ <br /> - ll -. �� DE <br /> PLAN ON FRSE SI ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE JIIIFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE-SR- <br /> 3/76 2M <br />