Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH- DISTRICT <br />(- FOK <br /> OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 �G <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PE9NIT Permit No. g_ <br /> THIS .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ?Q <br /> 7,2-- 7Dti =, .CG�F:57' ( 1�', :` (Complete In Triplicate) 0-Y P-_llar3? <br />' Aplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> I and/or install the work herein described. This application is made in compliance with San Joaquin <br /> Coun �Qr in 862 and the Rules and Regulations of the San Joaquin 1 Health Distri t. <br />`s OB <br /> AD RE 5 S/LOCATION <br /> CENSVS .�CT <br /> Own\ ' NameJA Phone <br />• l <br /> Address k) , --P.C1._ City . <br /> f Contractor's Name ZbAlf A License Phone ' <br /> -X- 4—M <br /> ff <br />--TYPE OF WORK (Check) : NEW WELL/ DEEPEN // RECONDITION /7 DESTRUCTION /_7ri PUMP INSTALLATION '/ / PUMP REPAIR/ / PUMP REPLACEMENT /-7 ' <br /> ` Other <br /> 5 <br /> DISTANCEITO NEAREST: SEPTIC :TANK SEWER, LINES PIT PRIVY <br /> �,,� p SEWAGE,DISPOSAL FIELD -dCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE,- PRIVATE DOMESTIC'WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OFVELL `r- CONSTRUCTION SPECIFIC TIONS <br /> Industrial .1 able Tool Dia. of Well Excavation <br /> e Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public-\, 1 Driven Gauge of Casing 40 <br /> �rri.gation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection s . } Rotary`s Type of Grout <br /> Disposal is Other , Other Information �--� <br /> Geophysical.. . i Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . /�/ State Work -Done <br /> F <br /> PUMP .REPAIR. / / State Work Done <br /> #- E t <br /> r} S <br /> DES-TRUCTION4OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure l <br /> I herebyagree to comply with, all laws and regulations�of the' San Joaquin Local. Health District a, <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 thest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO ING AN AFI i SPECTION. <br /> SIGNED j TITLE <br /> W.:Pt T` PLAN ON RE EASE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> ��"' <br /> APPLICATION ACCEPTED BY DATE s <br /> ADDITIONAL COMMENTS: , <br /> ` PHASE II-GROUT- INSPECTIO -- Y- PHASE III/FINAL -INSPECTI N <br /> INSPECTION_BY. DATE INSPECTION, BY DATE Vii/ ? ' <br /> E H 1426 Rev. 1-74 ' ' 1 w .. ._._.. - .. 3/76 2A <br /> f <br />