Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE: 66 1601 E. Hazelton Ave. , Stockton,_Calif. j <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-13-77 <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 mad in compliance with San Joaquin <br /> County Ordinance No. 1862 and1the Rules an R ulati s of th S oaquin Local Health District. <br /> �v <br /> JOB ADDRESS/ OCATION ENSUS TRACT/ <br /> Owner's Nam Phone <br /> 01 <br /> i <br /> l f <br /> Address / ' City/ Q 1 <br /> Contractor's Name - <br /> License/� ) hon <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR/ UMP REPLACEMENT J7 <br /> Other <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 uI <br /> Industrial i Cable Tool_ Dia, of Well Excavation <br /> Domestic/private i Drilled Dia, of Well Casing <br /> Domestic/public i_ _Driven- - +---- __- Gauge 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 r H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> `"PUMP-REPAIR: • /✓/� State Wo <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 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 /> information 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 .�, > TITLE 8GI}� 3P <br /> f 1 O A <br /> e4 (DRAW PI, T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -7 <br /> j ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />