Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION ICOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- <br /> THIS PBRHIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L! 8__;7 1 <br /> (Complete In Triplicate) <br /> Application is' hereby made to the Son 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 RulesandRegulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1� CENSUS TRA r�. . <br /> Owner's Name Phone 3� <br /> 01 <br /> Address - City ' <br /> Contractor's Name La •License �9d Phone 7f/s_? .� <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /-7 RECONDITION /? DESTRUCTION L7 � <br /> PUMP INSTALLATION IN PUMP REPAIR/ 7 PUMP REPLACEMENT /7 <br /> other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY • <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER j <br /> PROPERTY LINE PRIVATE_DOMESTIC WELL PUBLIC DOMESTIC WELL ' <br /> INTENDED USE "TYPE OF WELL CONSTRUCTION SPECIFICATIONS Cn <br /> Industrial - = Cable Tool Dia. of ,Well Excavation <br /> _ <br /> Domestic/private_ Drilled Dia. of Well Casing " �k <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 BY: :71 <br /> PUMP INSTALLATION: Contractor <br /> - - Type ,.of Pump .T .L`6�.rr �P H.P. <br /> PUMP-REPLACEMENT:.-, �*,L 7 State Work Done' <br /> PUMP~REPAIR: -7/7' State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 1 <br /> y '-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,weli-and-notify­them- before'-pdtting 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 ANP,A FINAL NSP ION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY _ <br /> FV"SEI - -_.--':--------:: .. <br /> A .KATION ACCEPTED BY <br /> �./'�f`(� DATE �`"I'�`7 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PBAS III FINAL INSPBCTION <br /> INSPECTION BYDATB INSPECTION BY DATE �'i <br /> E H 142'6 Rev. 1-74 _.. - 2M <br />