Laserfiche WebLink
jJOAQUIN LOCAL HEALTH DISTRICT <br /> iii OFFICE USE: 1.60.,. Hazelton Ave. , ,Stockton, Cal <br /> v <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. W-30 <br /> ----------- <br /> THIS <br /> -------^ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedtAR 3 - 1978 <br /> (Complete In Triplicate) <br /> Plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> d/or install the work herein described. This application is made in compliance with San Joaquin <br /> >unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> i <br /> )B ADDRESS/LOCATION CENSUS TRACT i <br /> mer's Name Phone- c- <br /> :dress <br /> City N <br /> �ntractor's Name 2 License Phone-f_ <br /> 'PE OF WORK (Check) : NEW WELL/ / DEEPEN / RECONDITION _ DESTRUCTION/ / UCTION /? <br /> PUMP INSTALLATION /-j---'PUMP REPAIR /—/—PUMP REPLACEMENT /'7 <br /> Other / / <br /> .STANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY °t <br /> SEWAGE DISPO% FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINZ0 fPRIVATE DOMESTIC WELL ~PUBLIC DOMESTIC WEL <br /> W, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �I( Cable Tool Dia. of Well Excavation 11 <br /> Domestic/private `'`� 44 Ig <br /> Drilled Dia. of Well Casing _ '• �' ! <br /> L A/1 <br /> Domestic/public Driven Gauge of Casing _��� k/e4�c�c!%�� <br /> Irrigation Gravel Pack Depth of Grout Seal Uj <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information [� <br /> Geophysical Surface Seal Installed_ By: nu)444ZL Q <br /> !MP INSTALLATION: Contractor <br /> Type of Pump H.P. . . <br /> fMP REPLACEMENT: / / ,State Work Done <br /> JNP ".REPAIR: / / State Work Done i <br /> .SjRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all Laws and regulations of the San Joaquin Local Health District <br /> id the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> =ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> LL DRILLERS REPORT of the well and notify them before putting the..well in use. The above <br /> iformation is true to th } best of y knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> .IOR TO �5�OUTINGA A P CTION <br /> {GNED " TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> -i.ASE I <br /> PPLICATION ACCEPTED BY DATE a _2-1 28 <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTTO PHASE /FIN INSPECTION <br /> VSPECTION BY DATE INSPECTION BY//51 <br /> F. H 1 L M nom.. 1_ -7 1177 9M: <br />