Laserfiche WebLink
Lo w l /4, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOBSFFICE USE: Z1601 E. Hazelton Ave. , Stockton, Calif. <br /> 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 !5-76 <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 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S`a a e J&a ,L/4.0 CENSUS TRACT <br /> Owner's Name j At j Phone <br /> Address A6 / y City <br /> Contractor's Name __X_14 OG' .� �c7. License # 372J PhoneP7 <br /> 1 ZL <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN -/-7 RECONDITION /_7 DESTRUCTION %f <br /> PUMP INSTALLATION /—/ —PUMP �PUMP REPAIR PUMP REPLACEMENT 17 <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 Cable Tool Dia. of Well Excavation U <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 0 <br /> -- Irrigation Gravel Pack Depth of Grout Seal j <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. if <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: / f State Work Done v r <br /> ES•TRUCTION 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 uee.. The above <br /> information is true to the beat o my knowled a and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AND A F INSP 0 . <br /> SIGNE - TLE <br /> cPI' <br /> (DRA OT PLAN 0 RSE SID�� .. <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' / ' 74' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II NAL IN PECTION <br />\INSPECTION BY DATE INSPECTION BY .. ATE <br /> i <br /> 1426--. .Rev. I-74 1-74 2M <br />