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 /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issue S'/2- 77 <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 II <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS LOCATION9FS77 . Ir A NSUS TRACT 06 <br /> Owner's Name IaLck , , Phone !� <br /> Address , City (a�J <br /> Contractor's Name F License ��.�� Fhone <br /> 'i. <br /> I <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR I I PUMP REPLACEMENT / 7 <br /> Other / / Ae <br /> DISTANCE TO NEAREST: SEPTIC TANK ��- SEWER LINES --V PIT PRIVY <br /> SEWAGE DISPOSAL FIELD S'O 1i CESSPOOL/SEEPAGE PIT daE OTHER <br /> PROPERTY LINE/O PRIVATE DOMESTIC WEL PUBLIC.DOMESTIC WELL �1 <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS (A <br /> Industrial Cable Tool` \1- -D a-:�^of Well Excavation <br /> �t, s • rf <br />.� Domestic/private Drilled q $, Dia:. of Well Casing � <br /> Domestic/public Driven Gauge �of Casing <br /> Irrigation Gravel .PackY` Depth4of Grout Seal <br /> IN <br /> Cathodic Protection -� Rotary Type of4•Grout i?�s7: <br /> Disposal 0ther � `�.� Other -e rination <br /> w3 p ~ ,Suraee Sea1` Installed B <br /> Geophysical ` 1 <br /> PUMP INSTALLATION: Contractor y oI xi <br /> Type of Primp , [[ , t3 <br /> _ L! Qb- ; <br /> IPUMP REPLACEMENT: f / State Work Done <br /> 4PUMP -REPAIR; / / State Work Done <br /> DESTRUCTION 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 GROUTING AND A FIN INSPECTION. <br /> SIGNED TITLE - Q <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> IAPPLICATION ACCEPTED B - •` DATE <br /> 'ADDITIONAL COMMENTS: <br /> PHA ITT INAL INS <br /> PHA E II ROUT INSPECTT N 1 DATE <br /> !INSPECTION BY DATE INSPECTION BY <br /> r 1177 _. 2M <br /> E H 1426 Rev. 1-74 &J4� d06 dei'/° - `" <br />