Laserfiche WebLink
SAN, JOAQUINTLOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: e 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-7/31r� <br /> THIS1PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-g-�� <br /> (Complete-In Triplicate) <br /> Application is hereby made to 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 an& the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> ,TOB ADDRESS/LOCATION <br /> ' Phone V{G� �0 ? <br /> Owner's Name <br /> city <br /> Address <br /> Glc <br /> License Phone <br /> Contractor's Name -1 <br /> W <br /> TYPE OF WORK (Check) : NEW WELL bEEPEN / / RECONDITION -.7 DESTRUCTION _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other / / <br /> --------------- <br /> /�n LINES PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER <br /> SEWAGE-DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE' � f .TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial-' Cable Tool Dia, of `Wel. Excavation <br /> k. <br /> _ Domestic/private +i Drilled <br /> Dia. of Well Casing 4 <br /> ublic t Driven Gauge-of� Casing _ O.y� <br /> Domestic/p Gravel. Pack Depth-of Grout Seal <br /> Irrigation f <br /> Cathodic Protection t Rotary Type of,Grout <br /> Disposal <br /> Other information. <br /> Geophysical 'i Other ! Surf ace"Sea1 Installed B <br /> �l <br /> PUMP INSTALLATION: Contractor . H.r. <br /> Type ;of Pump <br /> ,PUMP REPLACEMENT: <br /> / / State Work Done = <br /> 46 <br /> PUMP .REPAIR: / ,,State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well .Diameter <br /> Describe Material. and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Y g <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 GROU NG AND A FIAL IXSPECTION. TITLE <br /> SIGNED , <br /> ll W PL T' PLAN ON RE RSE SIDE <br /> FOR DEP USE ONLY <br /> PHASE I DATE 7' <br /> APPLICATION ACCEPTED B <br /> ADDITIONAL COMMENTS: P S /FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE �..-°�'y�- <br /> ` INSPECTION BY 'IDATE INSPECTION BY <br /> 1 psi., 3/? A <br /> t F. u 1L?A Rev. 1-74 <br />