Laserfiche WebLink
-- �� SAN JOAWIWL CAL HEALTH. DISTRICT <br /> FOh OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:. (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?_?,6 g-4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 21-1 <br /> (Complete In Triplicate) t <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 an Joaquin Local Health District. <br /> JOB ADDRESS dS . � ����� CENSUS TRACT <br /> Owner's Name Phone <br /> Address G City <br /> Contractor's Name/ G ate-' Z,icense #-I e94cI/9 Phone <br /> !�-- <br /> i <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN / / RECONDITION: / / DESTRUCTION <br /> --PUMP`INSTALLATION../"-/ ' PUMP REPAIR" / /T PUMP-REPZ;ACEMENT`/7 - I <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 V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia. of Well Excavation f� <br /> i/Domestic/private gilled Dia. of Well Casing �t <br /> Domestic/public _ Driven Gauge of Casing h <br /> Irrigation Gravel Pack Depth of Grout Seald <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal ..Installed By: ?-:� &WtL flys <br /> PUMP INSTALLATION: Contractor <br /> 5 Type of Pump H.P. <br /> 4 <br /> PUMP REPLACEMENT: ' / ./ State Work Done i <br /> i <br /> PUMP .REPAI / / . State Work Done �. <br /> QLDV/JO�/ <br /> DES-TRUTION OF WELL. Well Diameter _ _ Approximate Depth. <br /> Desarlbe Material and Procedure <br /> I hereby agree to comply with al`1�aw -a eg-ule-tkmrs(:rf-the Sa- 3oaq.uin 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 .5 <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 IN§XEjQTWN. y � <br /> SIGNED , TITLE / <br /> W.:PL T- PLAN ON REVERSE SIDE) 'f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I E <br /> APPLICATION ACCEPTED BY �U�_� _ � = - DA <br /> ADDITIONAL COMMENTS: <br /> PHA II G UT INSPECTION PHASE IITOINALINSPECTION <br /> INSPECTION BY- DATE p�T INSPECTION BY DATE -7 <br /> E H 1426 Rev. 1-7 3/76 2M <br />