Laserfiche WebLink
C SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> + APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - 7JBJ,0 <br /> f <br /> f 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.Joaquir <br /> County Ordinance No. 1862 and the Rulee/sJ and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ..�.�-+-�`� OZ.C.t.C� ,1 �r�- '� CENSUS TRACT <br /> "'Owner's Name Phone C ot 5� <br /> Address (' ti ,�p ` City <br /> Contractor's Name License #162-3 3 Phone 3�. <br /> t <br /> ± TYPE OF WORK (Check) : NEW WELL 7- DEEPEN /_/ RECONDITION �_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / J PUMP REPAIR 41el PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 3 " SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL IELY CESSPOOL/SEEPAGE PIT OTHER <br /> PUBLIC DOSTIC WELL <br /> INTENDED USE PR-OPER�ELINE <br /> OF WELLIVA�`E DOMESTIC, WELLC�,� RUCTIONSPECIFICATIONS �— <br /> - <br /> . Industrial _ - Cab1etTooil Dia. of Weil Excavation ISN <br /> Domestic/private Drilled Dia. of Weil Casing \ <br /> Domestic/public Driven Gauge of C sing <br /> Irrigation ty44 , Gravel- Paick Depth of G out Seal Rs <br /> CathodcePr:o�tettiori <br /> Rotary' Type of Out <br /> 5 <br /> _...-Other -.—Gt-he—r Ir�fo4mat-ion.� - <br /> h Geophysical ? Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ; i `--"' H.P. <br /> PUMP REPLACEMENT: / / State Work_Done <br /> F <br /> PUMP .REPAIR: � p <br /> � � State Work �one� <br /> ' DESTRUCTION OF WELL: Well Diameter i y!-, Approximate Depth <br /> F Describe Materi$1. arid' Procedure / <br /> I hereby agree to comply with all laws ;andiregulations of the'San Joaquin Local Health.,District <br /> and the State. of California pertaining * or regulating well '�onstruction. Within FIFTEEN DAYS <br /> after completion of my work on a new wei1, iI 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, inowiedge and belief. T WILL CALL FORA GROUT INSPECTION <br /> PRIOR TOG T G AND FINAL Z PECTION. <br /> SIGNED ; TTLE <br /> DRAW- L T' PLAN 'ON REVERS SIDE) <br /> OR,DEPARTMENT USE 014LY <br /> PHASE I / <br /> ' APPLICATION ACCEPTED BY w '`� DATE �0 <br /> ADDITIONAL COMMENTS: ; <br /> PHASE II GROUT INSPECTION `PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY r DATE <br /> E H 1426 Rev. '1-74 376 2M <br />