Laserfiche WebLink
v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE-OFFICE USE: c/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4664781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zd 12,X//0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued ,c-�-7G <br /> (Complete In Triplicate) <br /> Application is herebi made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is me:de..in compliance, with. San Joaquin' <br /> County Ordinance No. 1862 and the Rules" and Regulations of the San Joaquin Local Health District. <br /> J0B ADDRESS/LOCATION j7� -- G' t�`l � - -_.- � rvCNSUS TRACT <br /> Owner's Name ; � Phone , - 1 <br /> Address City. LC -, .r <br /> Contractor t s NameLicense <br /> ` .Phone <br /> ~TYPE OF WORK (Check): NEW WELL. �7 DEEP /? RECONDITION 17 DESTRUCTION /7PUMP INSTALLATION � PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> `.. <br /> Other-/,—/-- _. V — <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 /> k Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven. Gauge of Casing <br /> Irrigation. # l` k Grai;f�Pack Depth" of Grout Seal <br /> Cathodic Protection ':. Rotary'F; Type of Grout <br /> Disposal `` Other, . _ Other Information,-.' <br /> Geophysical Surface Se-w1 Installed By. . <br /> PUMP INSTALLATION: Contractor a <br /> Type .of Pump A.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP '.REPAIR: �/ / State Work Don'eT <br /> DESTRUCTION OF WELL: Well`'Diameter '`s •w 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 my knowledge and belief. I WILL CALL Fqg A GROUT INSPECTION <br /> PRIOR TO GROU NG 'AND NAL'INSPECTION. <br /> SIGNED TITLE d' AL1 <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Z <br /> APPLICATION' ACCEPTED BY DATE ' <br /> ! ADDITIONAL COMMENTS <br /> k PHASE IZ GROUT INSPECTION P T INAL INSPECTION <br /> INSPECTION BY DATE INSFLCTZON F' ti DATE 6 <br /> E H 1426 gev. 1-74 4175 2M <br />