Laserfiche WebLink
ti <br /> SAN JOAQUI,N LOCAL- HEALTH DISTRICT <br /> FOFi.r'OfFICE USE: 601 E. Hazelton Ave.: 'Stockton Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7�--3�3 <br /> THIS PERMIT EXPIRES 1"YEAR-FROM.DATE ISSUED Date Issued ) <br /> (Complete, ln, Triplicate) <br /> Application -is„ hereby made to the San Joaquin Lacal-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.. _ _ `.- es.�, 11 a CENSUS TRACT <br /> Owner's Name " . r aaPhone <br /> Address = S2 r_ City <br /> Contractor's Nam License iiT4ST?=Phone A&. /y <br /> TYPE OF WORK (Check)., NEW WELL DEEPEN '/-7 RECONDITION /-7 DESTRUCTION /? <br /> PUMP INSTALLATION PUMP REPAIR /? PUMP REPLACEMENT <br /> Other Jam' <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 77 <br /> Domestic/private Drilled Dia. of Well Casing ' ��.- <br /> Domestic/public Driven Gauge of Casing <br /> 90 <br /> _._.._..� Irrigation Gravel Pack Depth of Grout Seal 1 <br /> Cathodic Protection �— Rotary Type of Grout <br /> Disposal 4 Other, � Other Information <br /> GeophysicalSurface <br /> , ,....�.._ <br /> Seal Installed By: <br /> PUMP INSTALLATION; ContractorQIVA C_ to <br /> F Type of Pump a a H.P. <br /> PUMP REPLACEMENT / / State Work Done &47,C <br /> PUMP :REPAIR: /7 State Work Done e _ 'r / 14- «j*i <br /> ES1 UCTION 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 GR , TING D A FIVAL IN ECTION. <br /> SIGNED P TITLE <br /> (DRAW PLOT-PLAN ON REVERSE SIDE <br /> V <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 4. <br /> APPLICATION ACCEPTED BY DATE - � <br /> ADDITIONAL COMMENTS: <br /> PHAS II GROUT INSPECTIO PrtiASE . FI AL INSPEC I N <br /> INSPECTION BY DATE " INSPECTION BY DATE <br /> E H 1426 . <br /> � Rev. 1-74 <br />