Laserfiche WebLink
- ` SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOk.OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> F Telephone: (209) 466--678.1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. af-3 y� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby 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 ADDR.ESS/LOCATIONQ3 !v f <br /> CENSUS TRACT. <br /> Owner's Name - p P 5 .� f° - Phone 34 8 <br /> Address `7,d 0 3 city <br /> Contractor's Name 3 r icense # 507031 Phone -7V­,S;C <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /_/ RECONDITION /_7 DESTRUCTION %7' <br /> PUMP INSTALLATION � PUMP REPAIR /% PUMP REPLACEMENT <br /> Other <br /> _ Q <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 Too] Dia. of Well Excavation � <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depthf.of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed By: 7 <br /> PUMP INSTALLATION: Contractor ,•' fl J71 J` q �� <br /> Type of Pump _i <br /> - H.P. <br /> PUMP REPLACEMENT: . J5zr State Work Done <br /> 1 <br /> PUMP .REPAIR• a <br /> State. Work,-.Done _ + ! <br /> DESTRUCTION OF WELL: Well Diameter l <br /> �7�roximate Depth I <br /> Describe Material and Procedure a <br /> I hereby agree to .compiy 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 j <br /> information is true to the-best of- my .knowledge and belief. I WILL CALL FOR A GROUT. INSPECTION. <br /> PRIOR TO GROUT NG AND A FINAL INSPECTION. <br /> IGNED,. TITLE �, I <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PAR NT USE ONLY i <br /> PHASE I' „ i <br /> APPLICATION ACCEPTED BY2 /��= d� GLS DATE <br /> ADDITIONAL COMMENTS: P 4/7 <br /> PHASE II GROUT INSPECTION PHASE II /FINAL IN PECTIO�I <br /> INSPECTION BY DATE %, J INSPECTION BY D $ Z y <br /> :Z-7-z-,-- <br /> E H 1426 Rev_ 1-74 , IJ77 " Omf <br />