Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT E <br /> F0 OFFICE USE: �� 1601 E. Hazelton Ave. , Stockton, Calif. - <br /> Telephone: 1(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � '' <br /> � <br /> THIS PERMIT EXPIRES !1 YEAR FROM DATE ISSUED Date Issued 3-/,f'/J.s <br /> (Completd In Triplicate) <br /> Application is hereby made to the San Joaquin ocal 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 Refgulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION :�& 04 tire iq <br /> CENSUS TRACT <br /> L D it <br /> Owner's Name �. II Phone <br /> Ic <br /> Address a GrpZ City iv <br /> Contractor's Name pty .License �� hone a <br /> ly <br /> �, E <br /> TYPE OF WORK (Check) : NEW WELL :/ DEEPEN / 'f RECONDITION — <br /> DESTRUCTION /_7PUMP I _ALLATION'1/�/ PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK j _ SEWER� LINES '�:! PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 1, CESSPOOL'/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE 7OMESTIC WELLP..UBLIC DOMESTIC WELL <br /> I ENDED USE TYPE OF WELL ' CONSTRUCTION SPECIFICATIONS <br /> ndustrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public D ' en Gauge of Casing <br /> Irrigation ravel Pack Depth of Grout :Seal p <br /> Cathodic Protection Rotary Type of Grout C 4WEk <br /> Disposal Other Other Information <br /> Geophysical - Surface Seal Installed By: <br /> t <br /> PUMP INSTALLATION: . Contractor <br /> Type of Pump IM H.P. j <br /> f <br /> PUMP' REPLACEMENT: / / State Work Done 1' <br /> PUMP .REPAIR: <br /> / / State Work Done <br /> DESTRUCTION OF WELL: Well DiameterI� " � F <br /> � ; E Approximate Depth <br /> Describe Material and Procedure t f <br /> I hereby agree to comply with all' laws ;and regulations of this San Joaquin Local Health District <br /> and the State of California pertaiLng4to' or re'gudating well "eonstruction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, Twill furnish the San Joaquin Local Health District a' i <br /> WELL DRILLERS REPORT of the well and notify them --before-putting the..well in use. The above j <br /> information is true, to the best ofi,my knowledge. and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AND A FIN IN CTION. <br /> SIGNED 'eti •.�.,+ TITLE <br /> (I)RAW--P.LOT4PLAN:.ON.REVERSE_,..SID.E)— ,....�.�..,�,..�... , .��_..,.�.j <br /> FOR DEPARTMENT: USE ONLY f <br /> E <br /> PHASE I <br /> � r <br /> APPLICATION ACCEPTED BY DATE <br /> k.DDITIONAL COMMENTS: r3s <br /> PHASE II GR"UUT INSPECTION PHAS I FINAL INSPECT ON <br /> INSPECT ON BY DATE NSPECTION BY DATE 1� <br /> _� � � <br /> E H 1426 RPv. 1-7L I UP - 2M <br />