Laserfiche WebLink
!_ ,_ ' - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE- OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> c !THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) r-70 <br /> 4plication 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> /7-7 3--7- -9;:774,nr Ta W.0s-' <br /> JOB ADDRESS/LOCATION a' s CENSUS TRACT " <br /> Owner's Name 'Fh10�' <br /> Address 2311CA Cit <br /> Contractor's Name License # Phoner 3&: <br /> i <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INS ALLATIO PUMP REPAIR/ / PUMP. REPLACEMENT <br /> Other / / i p r /1 // <br /> DISTANCE TO NEAREST: SEPTIC TANK/ SEWER LINE 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 � l Cable Tool Dia, of Well Excavation <br /> il�omestic/private Drilled Dia, of Well. Casing <br /> Domestic/public Driven Gauge of Casing .,, I � <br /> ^Irrigation Gravel Pack Depth of Grout Seal JI <br /> Cathodic Protection Rotary Type of Grout ����� <br /> Disposal Other Other Information ' <br /> Geophysical. Surf ace Seal Installed By: <br /> PUMP INSTALLATION: Contractor40cr�� Ot <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diametera/�lApproximate 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 th best of my knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GMT AND FIN E CP ION, <br /> SIGNED TITLE <br /> !11(DRAWPfft PLAN ON REVERSE SIDE) 77",.,'R: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,44 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE -y } - ? INSPECTION BY �, DATE _Z- 2-o 78 <br /> C76 2M <br /> E H 1426 Rev. 1-74 <br />