Laserfiche WebLink
Y/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO OFFICE USE: 1601-E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466=4781 <br /> FI:AlAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: <br /> THIS PERMIT EXPIRES 1,YEAR FROM DATE ISSUED Date Issued 3-Z,5--74- <br /> (Complete <br /> -25-74(Complete In. Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct I <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 /> i 70� .. �ci �t*a-.- sT ,� �• zzS, 0�3z <br /> 'JOB ADDRESS/LOCATIONS CENSUS TRACT <br /> Owner i s Name _ jiff $ �q ._ _ Phone <br /> 0 <br /> Address / 3a - i.� n� V City &S C -, pd <br /> Contractor'a- Name I•` _ � dn�T�- S]a1 .,•,..•_,.__;...._ Licensec)-10 Phone 86a;--;2;2o7-' <br /> TYPE OF WORK (Check): . NEW WELL/? DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR 10V PUMP REPLACEMENT F7 r� <br /> Other /7 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> - Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of",Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic PrType Rotary T e of drout' <br /> Disposal other Other Information y <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> E Type of Pump H.P. <br /> Y <br /> PUMP REPLACEMENT: / / State Work Done <br /> AIR{ "'S'tato`Work Done <br /> ES.TRUCTION OF WELL: Well biameier _ - T 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 myrknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROWING AND FIN INSPECTION. � <br /> SIGNED TITLE - <br /> - __ (DRAW PLOT PLAN ON REVERSE <br /> FOR DEPARTMENT' USE ONLY __•.,._......_. <br /> PHASE I _ f <br /> APPLICATION ACCEPTED BY ATE <br /> ADDITIONAL COMMENTS: -'-' <br /> ro PHASE II GR NS ON ' P1"gAI4y AL INSPECTION <br /> . ?INSPECTION BY DATE INSPECTI DATE <br /> iE`,.H,;142b Rev. 1-74 1-74 2M . <br />