Laserfiche WebLink
FO _- ,S SJ JOAQ�N�'LOI:AL HEALTH ISTRICT v <br /> F CFTC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76 -7 9'y&) <br /> r THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED-1 Date Issuedf� <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 Joaquit <br /> ` County Ordinance No. 1862 and the Rules an Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCA ON J1' .441 . <br /> p CENSUS TRACT ' <br /> � I <br /> Owner's Name 54u— <br /> Ph e 4?445�--/W16) <br /> Address.�� c <br /> cit <br /> k <br /> Contractor's Name License <br /> TYPE OF WORK (Check) : NEW WELL/T7'DEEPEN '/-/ RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /? z <br /> °~'� Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Q SEWER LINES - PIT PRIVY :I <br /> SEWAGE DISPOSAL FIELD`. —" CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE S'PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ;TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial f1 Cable Tool { Dia. of Well Excavation <br /> y Domestic/private I Drilled Dia. of Well Casing. f <br /> Domestic/publica1 IDriveri Gauge of Casing 1� <br /> Irrigation Gravel Pack . : Depth of Grout Seal'' <br /> Cathodic Protection Rotar <br /> ..�fC Y Type of Grout 2. <br /> Disposal' Other Other IlifoTmatibn <br /> _Geophysical. r _ µ .-Surface .Seal ,Insta_lled..Bv:. _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: F_7 State Work Done <br /> PUMP -REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well.Diameter Approximate Depth <br /> De cribe�Mater�iaand P�aion <br /> ure <br /> comply with areg 'of the San-Joaquin ocal 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 furbish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the:. weill 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 GROUTING AND A FINAL INSPECTION. �� <br /> SIGNED 4; <br /> TITLE <br /> W PLIDT <br /> ... F EPARTMENT USE ONLY ; <br /> s I <br /> PHASE I 4w.�� <br /> APPLICATION ACCEPTED BY <br /> DATF �i <br /> ADDITIONAL COMMENTS: I # <br /> 1"TE <br /> SPECTION PHASE /FIN INSPECTION <br /> INSPECTION BY _ I INSPECTION BY DATE <br /> E H 1426 <br /> Rev. 1-74 j 3/76 2M <br />