Laserfiche WebLink
SAN JOAQUIN LOCAL HEaTH. 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 & <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> lations of the San Joaquin Local Health District. <br /> County Ordinance No. 1$62 and the Rules and Regu <br /> JOB ADDRESS/LOCATION <br /> �r� � CENSUS TRACT <br /> 9 Phone <br /> Owner's Name <br /> Address � L�'i�' / - "- City <br /> / 6 <br /> Contractorts Name `' License Phone <br />` TYPE OF WORK (Check) : NEW WELL D PEN / / RECONDITION / DESTRUCTION /-7PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT I-T <br /> Other L77 <br /> DISTANCE TO NEAREST: SEPTIC TANK ER LINES IT PRIVY d __-- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT /,0 OtE)THER <br /> PROPERTY LINEL5PRIVATE DOMESTIC WELL , PUBLIC DOMESTIC WELL P'~ <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation Z <br /> Domestic/private _ 'C Drilled Dia. of Well Casing <br /> _ - '-Gau$e of Casin �- <br /> Domestic/public Driven' i <br /> Irrigation u Gravel Pack, - Depth of Grout Seal <br /> Cathodic Protection `Rotary Type of Grout Pry <br /> ,. Other Information <br /> 1 � Disposal Other � <br /> k Geophysical tom' Surface Seal Installed By.:_ <br /> PUMP INSTALLATION: Coritractor <br /> Type of Pump �A H.P. z- 76 <br /> PUMP REPLACEMENT: State Work. Done <br /> - / / � <br /> it <br /> PUMP .REPAIR: /7-/ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: ' ' We`ll`Diameter <br /> Describe Material and Procedure <br /> , <br /> I{ I hereby agree to comply with all Taws 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 workhaf" nefa we11, T-dill"furnish `the' San-Joaquin-LocalHealth 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 AND A FINAL INSPECTI � <br /> SIGNED <br /> :F. <br /> !-,'(-bRAW4= RE SE SIDE) <br /> FOR DEPAR MENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> F � PHA II G OUT INSPECTION PHASE III/FI AL INSPECTIO <br /> INSPECTION BY DATE 3 INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. '1--74 <br />