Laserfiche WebLink
I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO <br /> -OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209)4 +66-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 7 SDW <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued s_ <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 Joaquina <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local ;Health District. <br /> JOB ADDRESS/LOCATION cam' CENSUS TRACT <br /> Owner's Name /!Z (ew Phone <br /> j f <br /> Address ��7GL f`(al�! o�dt City > O/,G�'l� <br /> Contractor's Name �c�f' �! S P q License 4 ,ZQ� Phone& 7 j� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL 'X DEEPEN / RECONDITION /_� DESTRUCTION /_7 l <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other /_7 + f . <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 WELL CONSTRUCTION.SPECIFICATIONS i <br /> Industrial l/ Cable Tool Dia. of Well Excavation G . <br /> .7 Domestic/private` Drilled Dia. of Well Casing iv <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth ,of Grout Seal 'zE i <br /> Cathodic Protection__ Rotary 4 �,„ Type of Grout e:Z.26,__ l-XI <br /> Disposal �� Other Other Information- <br /> Geophysical 1 Surface Seal Installed By:,f]y/ <br /> PUMP INSTALLATION: Contractor 7 WI p/r r• <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done � <br /> PUMP REPAIR: / / -State Work Done s \j <br /> DES'TRUCTION OF WELL: Well Diameter ` Approximate Depth <br /> Describe Material and Procedure ' <br /> r`f <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 /> aftertcompletion 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 A FIN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED "BY 6 DATE s <br /> ADDITIONAL COMMENTS: ti <br /> -----� ---PHA II• GROUT INSPECTION `” i `�" - — P ,I I/ NAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY ' DATE <br /> F. H 7 LL?A 'Poly- 1_7L + 1/77 2 / <br />