Laserfiche WebLink
a T SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z?� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _677 <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 Jo4qui: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION d't ,fr, . 0 A ` /f/i. E ��, P,( CENSUS TRACT <br /> Owner's Name / . . 1;.:e r _r"IAl Phone <br /> Address ' ; �Z- City <br /> Contractor's Nametib!„�.c ,, j"t 1� License Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /_] <br /> PUMP INSTALLATION /,�/ PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other /_7 <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _ c Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Tu r inGOr H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: I—W State Work Done , 3U A2 1�.bf1�— �/.� ld1461 -W <br /> )ESTRUCTION 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 /> ?RIOR TO GROUTING AND A FINAL I 0 <br /> SIGNED TITLE .11! r,_,j <br /> XDJRAV P 0 AN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE — y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRO . SP CTION PHASE JIUFINAL INSPECTION <br /> ,JNSPECTION BY ATE INSPECTION BY/ DATE -F-7 <br /> E H 1426 Rev. 1-74 lf]7 2M <br />