Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` FOE ti USE: 1601 E. Hazelton Ave. , ,Stockton, -Calif. <br /> �v 1 ; Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- ,2 4,/., <br /> t <br /> THIS PERMIT IrXPIRES 1 YEAR FROM DATE ISSUER Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to construct, <br /> i and/or install the work herein described. This application is made in compliance with San ,Joaquin <br /> County Ordinance No. 1$62 and the Rules and Regulations of the §an Joaquin Local Health District. <br /> Z L:.2yS. 'S'E "7'n�:J -e,k-7ZF /Y0 <br /> JOB ADDRESS/LOCATION t o } f' d t3 0 ' CENSUS TRACT ��7 .Z�n / <br /> r <br /> Owner's Name . <br /> Phone <br /> Address <br /> City/ CA' 6 4). <br /> Contractor's Name ,�,c� �- IIATLicense �'•� (o Phone 9('vc� fcCj <br /> TYPE OF WORK (Check): NEW WELL gj DEEPEN /% RECONDITION /7 DESTRUCTION 17 <br /> F PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT f <br /> Other �/% <br /> j ` 1� <br />' DISTANCE TO NEAREST: SEPTIC TANK [ SEWER LINES C PIT PRIVY , <br /> SEWAGE DISP S FIELD C SSPOOL/SEEPAGE PIT _ OTHER to <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTICrWELL_ <br /> INTENDED USE TYPE OF°WELLCONSTRUCTION SPECIFICATIONS <br /> Industrial 1 —. Cable Tool Dia, of Well Excavation <br /> Domestic/private 1 Drilled Dia. of Well Casing € <br /> Domestic/public. ! Driven Gauge of Casing <br /> k/IrrigationGravel Pack Depth of Grout Seal <br /> Cathodic Protection �Ro`ta'rydz &= <br /> Type of Grout i <br /> DisposalOth r Other. Information ' <br /> Geophysical <br /> 5 <br /> Surface_ Seal Installed By: e,3 <br />'PUMP INSTALLATION: <br /> _ Contractor <br /> Type of Pump H.P. <br /> It <br /> PUMP REPLACEMENT: / / State Work Done 3 <br /> PUMP .REPAIR: r <br /> State Work Done <br /> DESTRUCTION/OF,WELL: Well-Diameter. r <br />.-- � Approximate Depth <br /> ` Dies'crie Material and Procedure —"`—, <br /> I hereby agr 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 /> informaiion-is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED i ' ,.Q TITLE flj �ti <br /> =a z{➢RAW PLOT PLAN ON REVERSE -SI { <br /> 0 DEI'ARTMENVT�USE=ONJ:Y = - <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 2 F <br /> ADBvITIONAL COMMENTS: <br /> PHASE ;i, GROUT INSPECTION PRASE IT /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ,�o �� 7 4 <br /> IF <br /> EH � - 71 " <br /> 1426 Rev. 1--74 t . 1177. , " 2M <br />