Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> AFT 11CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7-,2,73 3✓ <br /> / THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-io '77 <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 i <br /> County Ordinance No. 1862 and the Rules and/ Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /4 �/o O o, L n G c , r�/ T� CP Qi-,00' ^J` 4N <br /> ySUS TRACT <br /> Owner's Name rJP4 'djap q� .. Phone <br /> Address � ( 7SC7d/ nc��_ ✓�'��._�` City <br /> Contractor's Name <br /> ScAor License # Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /� <br /> AL <br /> Other L/ ' <br /> I <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/private Drilled Dia. of Well Casing <br /> Domestic/public `"' " " Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal \�nn <br /> Cathodic Protection Rotary Type of Grout V. <br /> Disposal Other Other Information v <br /> Geophysical - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter c� Approximate Depth ;Vo_ <br /> Describe Material and Procedure � eA <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 <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 5KUYNG VD A F AL INSPECTION. <br /> SIGNED _ ___ -- TITLE - <br /> DRAWPL T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE I I/FINAL INSPECTION <br /> INSPECTION BY DATE '3 '`7 INSPECTION BY DATE �F <br /> 3/76 2M <br /> R H 1L96 Rai.. 1-76 <br />