Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH. DISTRICT ' <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 349 Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S}y-,77 <br /> ` (Complete In Triplicate) <br /> Application is hereby made t2 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 /> JOB ADDRESS/LOCATION i� 6 SCALtON CENSUS TRACT <br /> Owner's Name Phone �5 3 Z 3 Z� <br /> Address M116 6 L E,-r R City ,E54rAZ-OA/ - <br /> Con'tractor's Name �, License #;Z Phone - <br /> TYPE OF WORK (Check): NEW WELL J µ DEEPEN / / RECONDITION /� DESTRUCTION <br /> y { PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> t 4 Otherl/ / <br /> D,I#STANCE TO NEAREST: SEPTICSTANK ! 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 <br /> Industrial ! Cable Tool Dia. of Well Excavation <br /> _ Domestic/private ! Drilled Dia. of Well Casing 9 _. <br /> _ Doubestie/public - .--�,.Driven_���-.�„rGauge-of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection „ ' ` Rotary Type of Grout <br /> Disposal Other Other Information '_ <br /> Geophysical Surface Seal Installed By: //(JJ�"J�Gk <br /> PUMP INSTALLATION: Contractor <br /> Type ,of Pump H.P. <br /> PUMP REPLACEMENT: . State Work Done f�2Of0i �� <br /> PUMP .REPAIR: / / State Work Done <br /> DES,T'RUCTION OF WELL: Well .Diameter �. - :. ` Approximate Depth <br /> f Describe Mat ri.al and Procedure ' <br /> I Hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> atid 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 it <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 A4FINAL INS TON. <br /> SIGNED TITLE <br /> (DRAW PL T' PLAN ON RE. RS E S IDE) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> l <br /> APPLICATION ACCEPTED BY ' DATEVV <br /> ADDITIONAL COMMENTS: ' <br /> PH,WE. II ROUT INSPECTIO P S jft/FIN4 INSPECTION <br /> INSPECTION BY DATE6P 142 4ZZ <br /> INSPECTION BY DATE 0 Y <br /> 3/76 2M <br /> I -E H 1426 Rev. 1-74 200. ai-e t F . . <br />