Laserfiche WebLink
a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 70-K OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> AP LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ?,21L-2,1 <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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name L . 3 <br /> Address City ' <br /> Contractor's Name License # Phone , <br /> TYPE OF WORK (Check) : NEW WELL '/_7 DEEPEN -/7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR -/-7-pump REPLACEMEN 17 <br /> Other / 1 <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 �1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casingrt <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ti <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP :REPAIR: /% State Work Done <br /> r <br /> 1 U <br /> DESTRUCTION OF WELL: Well Diameter [0 Ap oximate Dept [ V 41 <br /> D scrib Materi 1 and Procedure Ge% X <br /> e4,m rn.f <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 DRILLS REPORT of the well and notify them before putting the -well- in-use.... The above <br /> informs io true to -the t.of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR ING p INS CT ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I `-- <br /> APPLICATION ACCEPTED BY DATE ` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I I FI AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY ATE y� 7 <br /> E H 1426 Rev. -I-744/75___2M <br />