Laserfiche WebLink
` = } SAN JOAQUJN-LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE: W 160 . E. Hazelton Add., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued IZ6 <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 Joaquin <br /> County Ordinance No. 1862 andAhe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO4,Sk,1,t't {,- CENSUS TRACT <br /> Owner's Name - (��� � Phone <br /> Address 0. o6 City <br /> Contractor's Name License Phone <br /> i' <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_% RECONDITION /—/ DESTRUCTION /-7 <br /> i <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other h / <br /> 7j- <br /> DISTANCE <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 /> k Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �' t <br /> Domestic/public Driven. Gauge of Casing <br /> g <br /> Irrigation Gravel Pack Depth of Grout Seal� <br /> Cathodic Protection Rotary Type of GroutI <br /> Disposal Other Other Information' 9621 <br /> Geophysical Surface Seal Installed By: ov -J-4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR;,.- :/y/ State;Work..Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withall laws and regulations of the San Joaquin Local Health District <br /> and the State of California. pe.rtaining 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 myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION F <br /> PRIOR TOG OUTING AND A INAL IWECT.IQN. _ <br /> SIGNED .TITLE <br /> DRA PI. T LAN ON RE 'RS E S IDE �,'� <br /> FOR DEPART=T USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTEDBY.. DATE <br /> ADDITIONAL COMMENTS: <br /> PE=J14GROUT INSPECTION _ - S - II "INAL INSPECTION <br /> INSPECTION BY DATE -�� INSPECTION B _ DATE�T�}-7 C0 <br /> r 3/76 2M <br /> E H 1426 Rev. 1-74 �' " :� <br />