Laserfiche WebLink
I I T <br /> L- SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE_ OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 456-5781 ��/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> J�JOB ADDRESS/LOCATION _ �7 7 � �" �T � ��, CENSUS TRACT �-$CQ Al" <br /> Owner's Name Phone 7 3 9—?.K3 <br /> Address .-- U City w4j p <br /> y <br /> 1 <br /> Contractor's Name � jmp �, �L]Y��\� tid.License # Phone Ry1 na <br /> x f f <br /> i s � <br /> I <br /> TYPE OF WORK (Check) : NEW-WELL`/DEEPEN '/ / RECONDITION /` / DESTRUCTION /_7 <br /> PUMP INSTALLATION /Ar PUMP REPAIR / '/ ° P.UMP REPLACEMENT /7 <br /> Other <br /> s <br /> DISTANCE TO NEAREST: SEPTIC TANK 720-. SEWER NES` 11 -+ PIT-PRIVY 6.SEWAGE DISPOSAL FIEI:D w7d:�, CESSPOOL/SEPAGE -PIT _OTHER + <br />' PROPERTY LINE - PRIVATEkDOMESTIC WELLag PUBLIC DOMESTIC WELL f <br /> INTENDED USE i TYPE OF WELL F CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Too.1��� 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 Se -� <br /> Cathodic Protection t�--Rotary ~; Type of Grout ;I- OArl�'� <br /> Disposal Other : s Other Information '"T,.cy6 P <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: . 'Contractor <br /> Type of Pump P. <br /> PUMP REPLACEMENT: / J. State Work Done <br /> Y f, <br /> PUMP .REPAIR: / / State Work Done <br /> ' a <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <br /> I hereby agree to comply'with all laws and regulations of the 'San Joaquin Local Health District <br /> and the Stare of California pertaining to or regulating we1l ��construction. Within. FZFTEEN 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. " Th'e, above <br /> infor is true to the of. wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO NG AND A FIN IN I �. <br /> SIGNED TITLE <br /> - (AW�,AT <PLAN ON REVERSE SIDS) <br /> i, <br /> FOR DEPARTMENT USE-'ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHA �Ij GROUT INSPECTIO s PHASE FINAL INSPECTION <br /> INSPECTION BY ATE - .INSPECTION BY ATE 7 <br /> 0 w.. <br /> 1 <br /> E H 1406 Rev-1-74 <br />