Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLIC mION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-33 S <br /> IS 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 hereitldescribed. 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 /> fLL <br /> JOB ADDRESS/LOCATION YCENSUS TRACT ` <br /> Owner's Name �. 0"! 9-i r r-A- Phone i <br /> Address / /„ City, <br /> 1 �y <br /> Contractor's Name %{.stc License # Phone�j&L� �,S'f� <br /> f i� <br /> TYPE OF WORK (Check) : NEW WELL1. '/ / DEEPEN %/ RECONDITION— / DESTRUCTION /� <br /> PUMP INSTALLATION �/ PUMP REPAIR/ / PUMP REPLACEMENT /� <br /> Other <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 <br /> Industrial f Cable Tool Dia, of Well Excavation <br /> Domestic/private A Drilled Dia. of Well Casing p <br /> Domestic/public ,I Driven Gauge of Casing <br /> Irrigation 11 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection f Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> 1 L� <br /> PUMP INSTALLATION:" Contractor ` <br /> Type of Pump ; e-s -.e.. <br /> H.P. <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <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 FINAL INSPECTION. <br /> SIGNED TITLE -- -- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 'APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> w PHASE II GROUT INSPECTION PHAS I /FI I SFECTION <br /> ' INSPECTION BY DATE INSPECTION BY ATE <br /> x/77 . 2M <br /> E H 1426 Rev. 1-74 <br />