Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: . 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No-7 <br /> - 9� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - 2,7 <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> hh L` _ <br /> JOB ADDRESS/LOCATION � �V �fx G ti am __-- CENSUS TRACT <br /> VA <br /> Owner's Name IP401U Tu�� 1 _-- Phone [5' J�-� [Q ou <br /> Address -- Q L ��. City <br /> r ! M <br /> Contractor's Name L.�L � ��.1�, j u�} � ,J License # �1 Q hone <br /> { <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN/ / RECONDITION / / DESTRUCTION /-7PUMP INST LATION / / PUMP REPAIR / J PUMP REPLACEMENT /7 <br /> Other / J — — - <br /> --- , <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 ELL CONSTRUCTION SPECIFICATIONS \ <br /> Industrial Cable Tool Dia. of Well Excavation /2-0 <br /> Domestic/private Drilled Dia, of Well Casing <br /> mastic/public Driven Gauge of Casing 21 <br /> rigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:__ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION 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 FOR A GROUT INSPECTION <br /> PRIOR TO G e TING ANDA INAd. INSPECTION, r3 <br /> SIGNED Q� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: -;4 <br /> PHASE II GROUT INSPECTION PHASE III]FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ,# , • 7 <br /> b/77 <br /> E H 1426 Rev. • 1-74 <br />