Laserfiche WebLink
a 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 /> C <br /> THIS PERMIT EXPIRES '1 YEAR FROM DATE ISSUED . Date Issued /�3 / <br /> �1 (Complete In Triplicate) <br /> Application is herey made too 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 ansa the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / r 12-z d9'/ CENSUS TRACT <br /> iOwner's Name o/���7`� II� v Phone $0- 3? _ <br /> Address j ''` City <br /> rt , License ��2��Phone <br /> Contractors Name - <br /> j TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION / / DESTRUCTION•,- <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT / <br /> E Other <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER 1INE!j. PIT PRIVY <br /> SEWAGE DISPOSAL—FI-ELD' " ,CESSPOOL/,SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia, of Well Excavation'� {A <br /> : 1 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 <br /> Disposal y Other Other Information <br /> Geophysical Surface Seal Installed B S' �` <br /> PUMP INSTALLATION: Contractor _ �- 7'`�5�� N <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: / / State WorODorie,f <br /> PUMP .REPAIR: / / State Work Done + <br /> DESTRUCTION OF WELL: Well! ameter; , 'Approximate Depth ^ <br /> Describe Material-„and Procedure <br /> t 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';,orr regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new,-wel+l,. 'I will„furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the• well in use The above. <br /> information is te to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTIN uD A OAL INSPECTION: '',” ; <br /> SIGNED Qu.�� t TITLE <br /> (DRAW PLOT PLAN ON REVERSE"SIDE} - <br /> y� , FOR DEPARTMENT USE,ONLY <br /> -PHASE I ,.�`�. '• �...��� .� .. � �.• '� � <br /> 77— <br /> 1 APPLICATION ACCEPTED BY 6 DATE 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS /FIN INSPECTION <br /> — lk <br /> INSPECTION BY ' DATE INSPECTION BY DATE(2--7 —`77 <br /> I q4 190 r 6/77 _ 2M <br />