Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7(;�-6 78 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 7_.ZQ 26 <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 o�,YS-110 r 111 Ave CENSUS TRACT <br /> Owner's Name S �zy Phone ` 7f'`' <br /> `7ij � <br /> Address ,Q P/l City L 9(f 4,c Dr1 <br /> Contractor's Name 7T19, License # o2/9ow Phone& <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR- PUMP REPLACEMENT /7 <br /> Other 17 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 Cable Tool Dia, of Well Excavation <br /> Domestic- _ <br /> /private Drilled Dia. of Well Casing � <br /> Domestic/public Driven Gangs of Casing <br /> Irrigation —� Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other ` ` Other Information <br /> Geophysical Surface' Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> .Type- of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP �REPAIR: State Work Done 42 <br /> 7 �V y,., <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 'construation. 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 GROUTING ANDA IN INSPECTION. <br /> SIGNED TITLE a <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> �^--- <br /> APPLICATION ACCEPTED BY DATE ` ?r a �j <br /> ADDITIONAL COMM ENT <br /> PHASE II GROUT INSPECTION PHASE.,.I INSPE O <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 - 4/75 2M , <br />