Laserfiche WebLink
SAN JOAQUIN LOCAL -HEALTH DISTRICT �J <br /> FOH FFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 D <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No., <br /> THIS PERMIT EXPIRES 1 YEAR FROM. DATE ISSUED Date Issued3,317o <br /> rll <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local. Health District ,for a permit to construct <br /> i and/or, install t.he_work herein described.. . This application is made incompliance with San Joaquin' <br /> County Ordinance No. ,1862 and the Rules ,and Regulations, of the San Joaquin Local- Health District. <br /> JOB ADDRESS,/-b446*T-1-9W- Z3tS ;.�, i�� CENSUS TRACT <br /> t . <br /> Owner's 'Name / 67 <br /> ��� �.f{ 1 1(,Lf� C711'�d`�f�'�'f --- - ----- Phone <br /> Address �:< .. _. City . <br /> Contractor's Name S� License 6���6 Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / RECONDITION / / DESTRUCTION /7 _ <br /> 1 PUMP INSTALLATION - PUMP REPAIR / / PUMP REPLACEMENT / / <br /> 10 0they <br /> DISTANCE TO <br /> NEAREST: SEPTIC TANK SEWER LIMES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> . INTENDED. USE .:a TYPE OF WELL ,- CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable Tool Dia. of Well Excavation <br /> i +}� Domestic/private ij -Drilled' Dia.'-of Well Casing <br /> t ` Domestic/public given r , Gauge of Casing <br /> - - - - — f <br /> )C Irrigation Gravel Pack Depth of Grout Seal „S f <br /> T— Cathodic-:Protection .Rotary Type of Grout: <br />' Dispsal Other Other Information <br /> Geophysical Surface Seal Installed By : <br /> PUMP' INSTALLATION: Contractor <br />.Y Type of -Pump H.P. " <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / 'State Work Done <br /> DES-TRUCTION 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 <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 /> f-PRIOR TO GROUTING AND A FINAL INSPECTION. L�/A <br /> SIGNED" W <br /> --Z <br /> L•T AN-ON--REVERSE-•S7DE)'-�r- <br /> FOR DE ARTMENT USE ONLY <br /> PHASE I 61. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL, COMMENTS: - <br /> PU4SII/CR INSPECTIO PHASE II ' FINAL INSPECTION <br /> INSPECTION BY - DATE .2 4Z2e INSPECTION BY DATE <br /> 0,/%7 2M <br /> ., �E H 1426 Rev. , 1-74 , <br />