Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH. DISTRICT ` <br /> POE OF'F'ICE USE: 1601 E. Hazelton Ave. , Stockton, Cali <br /> Telephone: (209) 466-6781 UPQ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 47 <br /> fool£- J-4*m.-jT 4.D. (Complete In Triplicate) 0,03 _ / L(O <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION/ - CCENSUS TRACT <br /> Owner's Namea:!t ,� CGc_ � Phone 4/S/7S� <br /> Address L, City 6,- , <br /> Contractor's Name (� ��� License #f 2 Phone 3 9-1-71 C <br /> t <br /> TYPE OF WORK (Check); NEW WELL /_7 DEEPEN'; /—/ RECONDITION /` DESTRUCTION /_7 <br /> PUMP INSTALLATION /j/ PUMP REPAIR . PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES k PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/,SEEPAGE PIT OTHER a <br /> PROPERTY LINE - PRIVAHE DOMESTIC -WELL" ' PUBLIC DOMESTIC WELL <br /> ;INTENDED USE TYPE OF WELL j CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tod,l Dia, of WeliI�Excavation {f� <br /> ;Domestic/private Drilled i Dia, of WelL-Casing-. .. <br /> ! Domestic/public Driven t_^ _...__ _GAuge Qf--Casing--�-- --- <br /> fIrrigation Gravel Pack Depth of Grout eal <br /> ' Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done f <br /> PUMP ,REPAIR: / State Work Done; <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 'sL1 <br /> Describe Material arid' Procedure <br /> i <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, 1I 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. <br /> PRIOR TO GRO NG AND A INSPECT ON. <br /> SIGNED TITLE <br /> W. PI-W"PLAN 'ON REVERSE SIDE :77 _ !:•' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �3 <br /> ADDITIONAL COMMTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ` <br /> i 3/76 <br /> E H 1426 Bev. 1,74 .. . <br />