Laserfiche WebLink
e- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR:OFFICE USE: �)'� 1,601 E. Hazelton Ave. , Stockton, Calif. <br /> r Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7V-436 lv <br /> THIS PERMIT EXPIRES-1. YEAR FROM DATE ISSUED Date. Issued 7:7-76 <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 appUcation 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 /> t � <br /> JOB ADDRESS/LOCATION 1� CENSUS TRACT <br /> Owner's Name Cmc � a Phone <br /> Address <br /> City ' ' , <br /> w Contractor's Name �- �7 ' � j <br /> 4 - /ifille� License ` Phone 7 1 g2 <br /> t TYPE OF WORK (Check): NEW WELL P7 DEEPEN •/? RECONDITION %f DESTRUCTION f7 <br /> PUMP INSTALLATION/ / PUMP REPAIR -/-7—PUMP REPLACEMENT /7 <br /> Other }/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE�,DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER / <br /> PROPERTY LINE _ PRIVATE DOMESTIC WELL'" PUBLIC DOMESTIC WELL W, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> s Industrial - Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. -of Well Casing <br /> Domestic/public i Driven Gauge of Casing '; <br /> Irrigation Gravel Pack Depth of Grout Seal 0) <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical """-"-- <br /> Surface Seal Installed BX: <br /> PUMP INSTALLATION: Contractor �. <br /> Type of Pump f,. H.P. ' <br /> PUMP REPLACEMENT: .., / / State Work Done <br /> PUMP �REPAIR: /7 State Work Done a . . . . . <br /> DESTRUCTION OF WELL: Y_ <br /> Wel] 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 a well and notify them before putting..the..well. in.use.... .The above <br /> information is true o. the•best•of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION i <br />'PRIOR TO GROUTI I IO <br /> SIGNED ���. TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FQR D PARTMMT USE ONLY <br /> PHASE I � � . <br /> APPLICATION ACCEPTE /iI VF'!✓1AI�f .' DATE 7- 7,6 I <br /> ADDITIONAL COMMENTS: - , <br /> PHASE II GROUT INSPECTI PHASE I FINAL INSPECTION <br /> INSPECTION 8Y DATE INSPECTION BY DATE _ i <br /> E H .1426 Rev. 1-74 <br />