Laserfiche WebLink
. i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.— <br /> Telephone: (209) 466-6781 77T3,�7/`' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '7 7-S'� W' <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '7"�-�- 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 <br /> County Ordinance No.' 1862 and the Rules Regulations of the San Joaquin Local -Health District. <br /> 7 5-5---7 <br /> JOB ADDRESS/LOCATION �+. � ENSUS TRACT <br /> Owner's Name A*_I, C...�v�i'D ��/ //��c�_// � fd�i ,nom. �.. hone <br /> t <br /> Address �C _? � sf �-,242 City r <br /> w� <br /> Contractor's Name / License Phone <br /> fir. <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN / / RECONDITION /_/ DESTRUCTION /7 I <br /> PUMP INSTALLATION PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ZO& SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSA; IELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL - <br /> �.. � INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation D <br /> _ Domestic/private.,_,, Drilled Dia. of Well Casing " - . U <br /> Domestic/public '- Driven - Gauge of Casing y,2 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodir_ Protection Rotary Type of Grout <br /> -_Disposal- Other Other Information <br /> Geophysical , 'Surface Seal Installed By: <br /> �. <br /> PUMP_INSTALLAT'ION: Contractor - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done `• - <br /> PUMP .REPAIR: <br /> / / State Work Done <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 o&,Zff0e?well and notify them before putting the -well in use. - The above <br /> information is true ,;o the best of- my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO E �tND <br /> SIGNED .. .. TITLE_ <br /> DRAW PIS T- PLAN 'ON RE ERSE S E) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE •I r., <br />`:APPLICATION ACCEPTED BY�` 2 � ,0 _ _ DATE . / # <br /> ILDDITIONAL COMMENTS: <br /> PHA E II GROUT INSPECTIOq PHASE 41II/FINAL INSPECTION ��� <br /> `�SPECTION BY DATE INSPECTION BY DAT <br /> v 3/7b <br /> E H 1426 Rev. `1:=74 <br />