Laserfiche WebLink
/,7J SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 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 ,-7z <br /> (Complete 4n Triplicate) <br /> Application is iaereby 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 `� CENSUS TRACT <br /> Owner's Name /fJ Phone o� 1 ti+��/� <br /> Address COA e �� � City LtQ �e�1',�_ , (.fi <br /> Contractor's Name , .License #, Phone - <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/.X/ DEEPEN/—/ RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTLATION/—/ —PUMP PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> AL <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL ViELD C SSPO L/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 <br /> Dome sCi-c/publ=ic - Driven- 'Gauge af-Casing" - <br /> Irrigation Gravel Pack Depth of Grout Seal L <br /> Cathodic Protection Rotary Type of Grout -�- <br /> Disposal Other Other Information Sl_ _ Au -e Y-- <br /> Geophysical Surface Seal Installed By: _ �! <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> a <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 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 ING D A FINAL INSPECTION. <br /> SIGNEDTITLE <br /> VOU DRAW ' PLAN ON -R-EWER <br /> SE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ��3 �7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE X2 -77 <br /> a. <br /> E H 1426 Rev. 1-74y"" ,!*_ 3/76 2M <br />