Laserfiche WebLink
' SAN JOAQUIN LOCAL HEALTH DISAICT <br /> FOR;-OFFICE USE: VI'1601 E. Hazelton Ave. , Stockton•, Calif. <br /> Telephone: -- (209) 466-6781.. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2LI7f1� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE'.ISSUEI} ; `` Date lsi(ie�d <br /> (Complete In Triplicate)•' b " <br /> Application is hereby made to the San Joaquin Local Health- District' far a permit to construct <br /> and/or install the work herein described. This application., is made-•-in cotipliancd;Vith`-:San Joaquin ' <br /> County Ordinance No. 1862 and the Rules and <br /> R^e�Jg/u`yl�atl'Ii` s of. the San 3oaquin--Local 1Healtti district'; <br /> .TOB ADDRESS/LOCATION 0,34X29p o p,(.,<< .°CENSUS TRACT <br /> Owner's Name Phone <br /> Address ' 'City <br /> Contractor's Name <br /> �� / !.�'� �hG License' 192/Phone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION � PUMP REPAIR /_7 PUMP REPLACEMENT E7 ' <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL D j <br /> INTENDED USE TYPE OF WELL CONSTRUCTION. SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> IN <br /> !Domestic/private Drilled Dia. of Well Casing w <br /> Domestic/public Driven GauS.ge <br /> a ge of Casing . <br /> Irrigation Gravel Pack Depth of Graut Seal S� <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 /> PUMP REPLACEMENT: /_1 State Work Done <br /> PUMP wREP_AIR: /7 '-State Work Done <br /> E&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 a <br /> WELL DRILLERS REPORT 2A the well and notify them before putting..the. well. in use.. The above <br /> information is trmoCo the-best of- my knows dge and belief. I WILL CALL FOR GROUT INSPECTION <br /> PRIOR TO GR AF�N ION. <br /> SIGNED _,,—TITLE <br /> (PJAW PLOT P REVERSE SIDE <br /> Id <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL CO TS: ` <br /> P INSPECTION PHAS INSPECTION <br /> INSPECTION B DATE q--_ INSPECTION BY DATE 4. <br /> i E H. 1426 Rev. 1-74 1-74 2M , <br />