Laserfiche WebLink
�..._ ✓ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR ZFFICE USE: V1601 g. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,?AL el/p <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 /> JOB ADDRESS/LOCATION -• CENSUS TRACT <br /> Owner`s Name -4 <br /> Phone � ���.���• <br /> Address .�Y_ �'-�-- v - � a <br /> - 19 city E_sZC4-j--e� <br /> '6ontractorts Name <br /> u tr LicenseQO 6 Phone'q?-- 63R y <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN '/-7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION REPAIR /_7-pump REPLACEMENT f7 <br /> Other f_1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD I e CESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE .. PRIVATE DOMESTIC-WELL - PUBLIC DOMESTIC WELL .s <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSI <br /> Industrial Cable Tool Dia. of Well-Excavation <br /> Domestic/private Drilled Dia. 'of Well,'Cesing <br /> Domestic/public Driven Gauge of Casing ` . <br /> Irrigation Gravel Pack Depth of Grout Seal `� <br /> Cathodic Protection Rotary Type of Grout' + <br /> Disposal Other Othet Information <br /> Geophysical `^. i Surf Seal Installed B : <br /> PUMP INSTALLATION: Contractort, <br /> { Type of Pu <br /> PUMP REPLACEMENT: / / :State Work Done <br /> PRE REPAIR: z... —/7-7, 'iState Work-Done` - �_ ..s.. - • . - ._ ; .* ��; <br /> 'ES-TRUCTION OF WELL: Well -Diameter Approximate Depth ..'' '�+ <br /> Describe Material and Procedure f <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 puttingthe- well in.use.. The above <br /> informs on is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION- <br /> PRIOR TO TING AND A FI -ION. <br /> SIGNED j TITLE <br /> `a <br /> RAW PLOT PLAN ON REVERSE SIDE) -v <br /> ,i FOR DEPARTMENT USE ONLY <br /> PHASE I ( , , <br /> APPLICATION ACCEPTED BY <br /> DATE .J <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I I SPE TIO <br /> INSPECTION BY .-_ DATE INSPECTION BY ATE <br /> f ` <br /> E H. <br /> 1425 Rev. Zry74 #. ;''/ x `` <br /> 1-74 2M <br />