Laserfiche WebLink
SAN JOAQUIN LOCAL ,HEALTH DISTRICT <br /> FOErOFFICfE USE: 1601 E. Hazelton. Ave. , Stockton, Calif. <br /> Ik Telephone: - (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75 <br /> THIS PERMIT EXPIRES 1•YEAR_FROM DATE ISSUED Date Issued <br /> i� (Complete In Triplicate) .(3 (-[2-0_02 <br /> Appli 'a'ion 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 /> ADDRESSS L�ATI6i d®V - -5'00 Ts+� A �i a P� ( y� p<3 t j 7:;c-L�,e-- CENSUS TRACT <br /> )k iAa <br /> owner's Name D � V& 't-P/. Phone <br /> AddressJ 6-7 G�/ C•v r - city <br /> Contractor's Name L �U Licensee�Phone Ij-4,o6 <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN /-7 RECONDITION 7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR X PUMP REPLACEMENT <br /> Other / / ,J <br /> DISTANCE TO NEAREST: SEPTMTANK SEWER LINES PIT PRIVY <br /> /'SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> y� ✓PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDER USE,/ TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Z . ! Cable Tool Dia. of Well Excavation <br /> ' Aomes.tic/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 BX: C_ <br /> PUMP INSTALLATION: Contractor <br /> `. Type of Pump H.P. <br /> PUMP LACEMENT: State Work Done <br /> PUMP •PAIR:.�. - �^' State-Work:Done---�p&j <br /> i <br /> ,MTTRUCTION 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> \ FOR DEPARTMENT USE ONLY <br /> PHASE I; - <br /> � DATE. <br /> PLICATION ACCEPTED BY' -V� f <br /> ADDITIONAL COMMENTS: <br /> ' PHASE II GROUT INSPECTION PHASE WI/FINAL INSPECTION <br /> ` INSPECTION BY -T DATE INSPECTION BY DATE -2I-W <br /> ! E H 1426 Rev. 1-74 1-74 2M <br />