Laserfiche WebLink
�C/l/7// SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOAt"QFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 7APP ICATION 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 Sen 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. I CENSUS TRACT <br /> Owner's Name N G'r /~ �' S' Phone _ 7S`5 3 <br /> Address ZA 1' 37 G,, I IQ "LZA &L R p City <br /> Contractor's Name � I r ' <br /> t /.' P r��c,! �-t_� "�� Li cen s�� � � Phone 7 11;�1 <br /> TYPE OF WORK (Check) : NEW"WELL-I --D4EEPENt/_--7—RECONDITION--/�- DESTRUCTION Kf-7 <br /> _ <br /> _ PUMP INSTALLATION I I PUMP REPAIR /_7 PUMP REPLACEMENT 1 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANKIV#be S LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELDD4%,o CESSPOOL/SEEPAGE PIT OTHER. <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL'' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI S <br /> x Industrial Cable Tool Dia. of Well Excavation � . <br /> Domestic/private Drilled Dia. of Well Casing -_�- <br /> � —,Domestic/public - -Driven Gauge of Casing <br /> , X Irrigation `Gravel-Pack Depth--of.Grout Seal , <br /> . T . <br /> - � -�.�r:_._ � �_ .�,,,..mow._. _- <br /> Cathodi'c�'rotecti-ofli �`R6t --- -- Type o€ Giout . - ' <br /> ,Disposal Other Other Information <br /> Geopfiysica Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ,Type of Pump H.P. <br /> E_ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP_:REPAIR:-,.,7 ., _ ,..-weL:7—State_-Work-Done <br /> r <br /> ES;IRUCTION OF WELL Well Diameter 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.be t of my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GR UTING AND A FIN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> - -_. -_-.,.. . -- <br /> APPLICATION ACCEPTED BY�. .r- •� - - -�'"" ,, . � �, ". M.- '4 Win...._ '"""DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROAT INSPECTION PHA I N INSPECTION <br /> k <br /> INSPECTION,BY _ DATE INSPECTION BY DATE <br />` ; ' E, H 1426 Rev. 1-74 1-74 2M <br />