Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71 ob <br /> 1� ac e.Y THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued e'_-.26-47 <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 � . Dfa !`� CENSUS TRACT <br /> Owner's Name 'rd/L Phone - <br /> Address 141-VCity / (� 1 �F. <br /> Contractor's Nameh/ �. r 7- kli '&41i LicensePhone4V 4-A �1 <br /> N <br /> TYPE OF WORK (Check) : NEW WELL/�EEPEN / / RECONDITION f_1 DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 9V SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ,>10 CESSPOOL/SEEPAGE PIT,>Z40 OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Cr� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _fG Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout cj i <br /> Disposal Other Other Informati n <br /> Geophysical Surface Seal Installed B zz(a --_ - <br /> PUMP INSTALLATION: Contractor / I/ / Q� <br /> Type of Pump H.P. j <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION_OF WELL: Well Diameter Approximate Depth <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 GR U INGA FI INSPECTION. <br /> SIGNED , TITLE /f�l9�Ii <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �Z 7 A';? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT qNSPECTION PHASE III INAL INSPECTION - <br /> INSPECTION BY DATEGJ.•_� '7�� __ - INSPECTION BY DATE `� •,M:� •7 7 <br /> E H 1426 Rev. 1-74 <br /> ' 1177 2M <br />