Laserfiche WebLink
n <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r <br /> Telephone: '(209) 466-6781 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - 4 8 <br /> f <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued z/-S-7 <br /> (Complete In Triplicate) t <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 pplication is made in compliance with San Joaquin '. <br /> County Ordinance No.' 1862 and 'the .Ru1 d R ations of the San Joaquin Local Health District. <br /> l <br /> JOB ADDRESS/LOCATION f CENSUS TRACT <br /> Owner's Name L ��L. Phone <br /> j <br /> Address f City <br /> License/�f G 3�4honef'/"�'�? 7 <br /> Contractor's Name 1 <br /> i <br /> TYPE 0]?;YORK`-(Check) . 'ANEW 'WELD / / l DEEPEN / I RECONDITION- I I DESTRUCTION /� <br /> PUMP INSTALLATION :/ I PUMP REPAIR PUMP .REPLACEMENT I_ <br /> Other / I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT 'PRIVY <br /> ' SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER k <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 /> IrrigationGravel Pack Depth of Grout Seal <br /> Cathodic Protection& Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed By:_. <br /> i <br /> k <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / <br /> State Work Done <br /> i <br /> ^,PUMP REPAIR'-" ]�"�State'Work Do <br /> " t 1 <br /> DESTRUCTION OF WELL: Well4Diameter 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 /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE J 1 <br /> DRAW PI T PLAN ON RE FRSE SIDE) <br /> _ a <br /> OR DEP TMENT USE ONLY <br /> PHASE I n ` <br /> DATE <br /> APPLICATION ACCEPT <br /> ADDITIONAL COMMENTS: �+ <br /> PHASE If GROUT INSPECTION PHAS III/FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />