Laserfiche WebLink
` SAN JOAQUT'N LOCAL HEALTH DISTRICT p <br /> SOF OFFICE USE: 1601 E. Hazelton Ave . , Stockton, Calif. <br /> Telephone: (209) 466-6781 f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7#__S_4) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> f (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 Jo4quin <br /> fff County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS LOC TI <br /> / A ON . �2 3 CENSUS TRACT <br /> 4 <br /> Owner's Name FG ! Phone �e4s-o74 <br /> Address 3c)Z City loc k Is,- <br /> Contractor's <br /> s,-Contractor's Name License 4f.3�?J`_/ 4 Phone 1 <br /> 14E <br /> E <br /> TYPE OF WORK (Check) : NEW WELL CJ DEEPEN%J RECONDITION /__7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other — <br /> DISTANCE TO NEAREST: SEPTIC TANK fiS,EWER LINES PIT PRIVY y <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 /> ' <br /> Industrial � Cable Tool of Well Excavation <br /> X_ Domestic/private Drilled Dii. of Well Casing <br /> Domestic/public Driven Ga ge of Casing 12 <br /> Irrigation GravePac Dy th of Grout Sell {� <br /> Cathodic Protection RotaryT e of Grout S' � �L C'�_yYj <br /> Disposal Other Other Information► -- <br /> j <br /> Geophysical Su face Seal Installed By: <br /> ! PUMP INSTALLATION: Contractor <br /> ' Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP -.REPAIR: / / State Work Done,.. <br /> A <br /> IDES•TRUCTION OF WELL: Well Diameter Approximate Depth 180 <br /> Desc ure 1 <br /> . I hereby agree to comply wi all laws and regulat'ons of t?*-, San Joaquin Local Health District <br /> sand the State of California ertaining to or regul ting well ' struction. Within FIFTEEN DAYS <br /> after completion of my work n a n�cd� I will urnish th Joaquin Local Health District a <br /> ' WELL DRILLERS REPORT of the ell and notify them b fore putting t ell in use. The above <br /> . information is true to the b belief. I WILALL FOR A GROUT INSPECTION <br /> 'PRIOR TO GBDIMNG 44 A FIN INSPECTION, <br /> SIGNEDflng ell TITLE <br /> VVY 4- (DRAW PLOT PLAN ON REVERSE SIDE) 3 j <br /> t FOR DEPARTMENT USE ONLY <br /> ,PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 7 <br /> ADDITIONAL COMMENTS: ' <br /> I PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY _ DATE 7-2 A •y7 INSPECTION BY DATE 2'Z a •�� <br /> > E H 1426 Rev. 1-74 �r� _ <br /> 1177 2M <br />