Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -30tr> <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued j-.4-1-76 <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 S/ ,� � ' &Y Vj tVA CENSUS_ TRACT <br /> Uzi - welOM 1 �.. .. <br /> Owner's Name �- & Phone p 2-2;2.7?''j <br /> Address — --- ��� , City <br /> Contractor's Name Ucense # Q&9 Phone <br /> TYPE OF WORK (Check): NEW WELL/T DEEPEN '/7 RECONDITION /? DESTRUCTION j'7 <br /> PUMP INSTALLATION /_/ PUMP REPAIR j� PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK -12QL SEWER LINES - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL�ZaL PUBLIC DOMESTIC WELL ` <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (1 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> V 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 _1 Rotary Type of Grout <br /> Disposal Other Other Information <br />�^Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done 1 <br />)ESjRUCTION 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 re ulateing well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I wi'N �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 />'RIOR TOj GF2UTING MRZ& FINAL SP ION. <br /> SIGNED G [ L TITLE ZIA J4. <br /> W <br /> Pur <br /> PLAN ON RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br />!APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT- IN ECTI N PHASE III FINAL INSPECTION <br /> INSPE ION BY 11DA INSPECTION BY _ DATE <br /> 44 t 6 Rev n 1-I�4 / �` 2M <br />