Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _YO F OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> dPLICATION <br /> Telephone: (209) 466-6781 <br /> FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. x131 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued y- 7 <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 CENSUS TRACT <br /> Owner's Name , Phone <br /> Address CSI City C aCr3.Qo�"l <br /> Contractor's Name a- ° - 0.3'.2 _3ls-1 F <br /> nc_. t License II& Phone 5'3,q--i�2.y7 <br /> a <br /> TYPE OF WORK (Check) : NEW WELL 1-71L DEEPEN/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR J / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ' <br /> qtr 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 4. <br /> Domestic/private Drilled Dia. of WelCasing,, <br /> Domestic/public .. ' Driven $' Gauge of Caknauj&,Vfc <br /> f/ Irrigation V Gravel rack Depth of Grout Seal 177k <br /> Cathodic Protection �T Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:___ A, <br /> PUMP INSTALLATION: Contractor{ <br /> Type of Pump - H.P. <br /> P. P <br /> REPLACEMENT: / / State Work Done F <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> a Describe Material and Procedure <br /> I Hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> andrthe 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 l <br /> information is true to the best of my knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AND A FINA INSPECTION. <br /> SIGNED J TITLES , <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY Zd DATE V '74 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA5E /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7/- 17-717 <br />