Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F-0R70FFICE USE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)'' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 `q O 16 CENSUS TRACT " <br /> Owner's Name Phone F <br /> Address21 <br /> - Cityr�.. <br /> Contractor's Name ,License 11,;.v -� Phone �2eZEKZ7 { <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / jC DEEPEN /7 RECONDITION /-7 DESTRUCTION /7 ' <br /> PUMP INSTALLATION �/ PUMP REPAIR /� PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: ' SEPTIC TANK V2 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Z,�JV I 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 v } <br /> Domestic/private Drilled Dia. of Well Casing ' \`'\ <br /> Domestic/public Driven Gauge of Casing _ �— Vx <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: -' = Contractor <br /> `Type�of Pump H.P. `? <br /> i <br /> PUMP REPLACEMENT. "'- - / S ,Work Done —� <br /> PUMP :REPAIR: State Work Done t <br /> DESTRUCTION° OF WELL: Well Diameter . l E 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 tfle State of California pertaining to or regulating well "construction. Within FIFTEEN DA S. <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distrijt''a <br /> WELL DRILLERS REPORT of the 1 and notify them before putting the well in use.. The above <br /> information`is t best of my knowled a and belief. . I WILL CALL FOR A GROUT INSPECTION <br />. PRIOR TO GROUTIN AN <br /> 6-7 <br /> SIGNED TITLE <br /> (MW PLOT PLAN ON REVERSE SIDE) <br /> ( FOR DEPARTMENT USE ONLY <br /> PHASE 'I <br /> I` APPLICATION ACCEPTED BY _ � -- DATE !/-/ ` ?? <br /> ADDITIONAL COMMENTS: <br /> P T INSPECTION ' ' ` PISA INSPECTION <br /> INSPECTION BAA-V- DATE INSPECTION BY ^^DAAT�T,E <br /> E H 142 �R �/1-74 - 1177 2M J <br />