Laserfiche WebLink
SAN JOAQUIN" LOCAL HEALTH DISTRICT <br /> (OFFICE USE: 1601 E .Hazelton.Ave , =Stockton, Calif. <br /> Telephone: . -•.(209) 4666781 <br /> AP LICATION FOR WELL CONSTRUCTION OR PUMA' PERMIT Permit No. Z- Zle <br /> THIS-PERMIT EXPIRES 1-YEAR.-FROM DATE ISSUED Date Issued ) -13-77 <br /> a (Complete InrTriplicate) <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.- Thi application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rul.es �,and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Ax :. . '� n CENSUS TRACT <br /> �Ov er's Nama R7 19 D Claim Phone e-&7 <br /> Address'.. City ;Sj3,C�1.✓ <br /> Contractor's Name 1 License # 29 Phone �J <br />' - _ �.<.,...�,... -� ;� - ._ -� - +..-•�.:_�,.-�.-= _� - r . _��_ .. ��=;,�:.r..=:--.mfr � . _ _- <br /> TYPE OF. WORK (Check): NEW WELL 17 DEEPEN -/7 RECONDITION /7 DESTRUCTION f7 <br /> ! -�--- —PUMP-INSTALLATION / / PUMP REPAIRS& PUMP REPLACEMENT -7 <br /> Other % J <br />",. DISTANCE TO NEAREST: SEPTIC TANK SEWER"LINES� ;... PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> IPROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED -USE 2 TYPE OF WELL I CONSTRUCTION SPECIFICATIONS {� <br /> Industrial Cable Tool Diaof Well Excavation (`U <br /> Domestic/private Drilled Dia.. a€ Well Casing <br /> Domestic/public. Driven Gauge'-'of Casing <br /> Irrigation « . Gravel'Pack Depth of Grout Seal �r <br /> Cathodic Protection Rotary -Type `of Grout' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: _ Contractor <br /> 'Type 0f Pump - _- - _Y._ _ H.P. <br /> PUMP REPLACEMENT:- <br /> E/:4.S tate,Work Done i <br />-PUMP :REPAIR: "Sat-4,51i <br /> PES7RUCTION 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 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 FQR A GROUT INSPECTION }, <br /> PRIOR TO GROUTING ANDA N INSPECTION. <br /> SIGNED TITLE <br /> � . DRAW PLOT PLAN ON REVERSE SIDE <br /> ' FOR DEPARTMENT USE ONLY <br /> c ' <br /> PHASE. I <br /> APPLICATION'ACCEPTED BY - DATE J 113 177, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT .INSPECTION P%"z_Zz;/jaNA1, INSPECTI N <br /> INSPECTION BY f^.° =s DATE' INSPECTIO "" DATE <br /> ii ` 1E H 1426 Rev. 1-74 ' 1-74 2M <br />