Laserfiche WebLink
SAN- JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE i3SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> VICPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7 7- ff <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued LI� <br /> A,AJO CL— <br /> d (Complete In Triplicate) <br /> Application is hereby madeito 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of. the San Joaquin Local Health District. <br /> r <br /> JOB ADDRESS/LOCATION #4,26ZaCENSUS TRACT " <br /> k <br /> Owner's Name Phone 3/�4?" oCQJ <br /> Address City <br /> Cont a-cc or's Name T f - License <br /> t� <br /> ' TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/�CONDITTON / / DESTRiICTTON /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /-/ PUMP REPLACEMENT <br /> 4 Other <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 let <br /> - <br /> Domestic/private Drilled Dia. of Well Casing +� <br /> t. <br /> Domestic/public Driven Gauge of Casing. <br /> ► Tle-1frrigation Gravel Pack Depth of Grout Seal <br /> --Cathodic P-ro-tect:�on-+ �--�- <br /> -- Rot —'Type-of t <br /> Grou <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> t ► -� <br /> y PUMP INSTALLATION_: Contractor <br /> Type!. of,Pump Tri „ 1.. H.P. /p <br /> PUMP REPLACEMENT: ' / /:� State Work Done <br /> r <br /> PUMP REPAIR: / / State Work Done <br /> — a <br /> V. <br /> DESTRUCTION -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 'iO work on a new well, I will furnish the San Joaquin Local Health District z <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 INSPECTI N <br /> PRIOR TO GROUT G `AND FIN INRECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I <br /> APPLICATION ACCEPTED-BDATE 9 <br /> ADDITIONAL COMMENTS: ! <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ti ( DATE INSPECTION BY DATE/� - <br /> ETH 1426 Rev. . 1-74' � ° � 6/77 . 2M <br />