Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> /r_FR,OCalif. <br /> OFFICE USE: j / 1601 E. Hazelton Ave. , Stockton, ; <br /> (/ I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 t S G V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-111-76 <br /> (Complete In.Triplicate) <br /> Application is hereby made t�jthe. 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 Mules and Regulations of the San Joaquin Local Health District. , <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> yGG- �G 3 r <br /> Owner's Name , G- <br /> Address . - % /� G City S7066i1 21Y <br /> Contractor's Name Z✓gL12 W/-;:,Z/ �^ y �� License AGO Phone L - sfT <br /> TYPE OF WORK (Check): NEW WELL L/ �,. DEEPEN -/ RECONDITION /-T• DESTRUCTION rT f <br /> PUMP' INSTALI:ATION_ /_7 PUMP REPAIR /_7 PUMP REPLACEMENT 17 <br /> ' Other )/ / 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK '.SEWER LINES PIT PRIVY <br /> SEWAGE•DISPOSAL FIELDc CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � <br /> fINTENDED USE TYPE OF WELL- CONSTRUCTION SPECIFICATIONS V <br /> Industrial ;f Cable Tool Dia, of Well Excavation <br /> T Domestic/private t Drilled Dia. of Well Casing <br /> Domestic/public : Driven Gauge of Casing <br /> Irrigation i Gravel Pack' Depth of Grout Seals <br /> Cathodic Protection I Rotary Type of Grout �1 <br /> Disposal i Other Other Information <br /> Geophysical Surface Seal Installed 'By: - <br /> t <br /> 'UMP INSTALLATION -Contractor <br /> Type 'of Pump ,. H.P. <br /> F u <br /> f PUMP REPLACEMENT; / / State Work Done <br /> PUMP '.REPAIR: /_7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 1:� Approximate Depth <br /> Descrlbe. Material and Procedure 1. <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 &= Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the swell 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 TOG IN AND A F NAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN- ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> -ITASE. i <br /> ?LIGATION' ACCEPTED BY DATE / �6 <br /> ADDITIONAL COMFITS: - <br /> PHASE II GROUT INSPECTION PHASE III FINAL SPECTION <br /> ' INSPECTION BY DATE INSPECTION BY DATE -Z 6 <br /> - r 2M <br />