Laserfiche WebLink
Lpq SAN JOAQUIN LOCAL HEALTH. DISTRICT -p <br /> FOE - FFAU USE: ` . 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR.. PUMP PERMIT Permit No. ;97 9jo <br /> THIS FERMIT EXPIRES l YEAR FROM DATE ISSUED Date, Issued 1fj_/. 76 <br /> (Complete In Triplicate) <br /> Application is hereby made to}Ithe 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. 1$62 andtheRules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . . Cp r1l,.r �_ � A" CENSUS TRACT <br /> Owner's Name �~ ✓,b Phone / <br /> Address <br /> / 62" . // City [�� a{ '^ <br /> ii <br /> Contractor's Namec,.v License # 1 37 Phone I <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION Ll PUMP REPAIR � PUMP REPLACEMENT /� <br /> AL <br /> Other <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY a <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 I Cable Tool Dia. of Well Excavation - <br /> _ Domestic/private I Drilled Dia. of Well Casing <br /> �Domestic/public I Driven Gauge of Casing V <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 11 Rotary 'Type of Grout <br /> Disposal li Other Other Information <br /> Geophysical .. Surface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: Contractor. <br /> Type of Pump --- H.P. /f` <br /> PUMP REPLACEMENT /-7/ St ate Work Done''..,. <br /> -- � <br /> PUMP .REPAIR: / / State Work Done �,y <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> i <br /> I hereby agree to comply withall 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..k owledg a belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G T NG AND A'FTNAI! <br /> SIGNED - � ITLE <br /> W: I; PLAN ON E SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE � <br /> 3/76 2M <br /> i E H 1426 Rev. 1"74 <br />