Laserfiche WebLink
ESAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ., <br /> F <br /> Telephone: -(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 27-4&p <br /> 6 7 <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 /> f <br /> .TOB ADDRESS/LOCATION � �!�/ - CENSUS TRACT <br /> Owner's Name Phone <br /> F <br /> Address ddLj=z City <br /> Contractor's Name 1169, r- License # ' fo 'hone - <br /> TYPE OF WORK (Check) : NEW WELL %T DEEPEN '/7 RECONDITION f DESTRUCTION /-7 <br /> PUMP INSTALLATION j� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /gip CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL X ! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �jF7 Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel PackDepth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout . <br /> Disposal. Other Other Information ' <br />! Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> i Type .of Pump H.P. <br /> PUMP REPLACEMENT: , / / State Work Dane <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 best.of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> JPRIOR TO GROUTING AND A VI AL INSPECTION. <br /> SIGNED J TITLE ��� __--- <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DMARTMENT USE ONLY <br /> PHASE I <br /> BY DATE -2I7—APPLICATION' ACCEPTED77 <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHA§ I INSPECTION <br /> ' INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Ray. 1.-74 � _ 4/75 2M <br />