Laserfiche WebLink
4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 r/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �Cl � lay <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3� 7 7� <br /> (Complete In Triplicate) f <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 <br /> =� <br /> /LOCATTON of Lel _ L4�LlS r CENSUS TRACT <br /> Owner's Name Phone Z <br /> Address City <br /> Contractor's Name License = PhoneY,0- 4,`-67W,/� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN -/ / RECONDITION / / DESTRUCTION /-7 f <br /> PUMP, INSTALLATION REPAIR / / PUMP REPLACEMENT 1-7 ` <br /> Other / / <br /> NI <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> !I r, PROPERTY LINP��PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL F <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ` <br /> Industrial Cable Tool Dia, of Well Excavationp r <br /> Domestic/private Drilled Dia. of Well Casing ? <br />_ Domestic/public 3 Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection' Rotary Type of Grout 04F � <br /> Disposal Other Other Information <br /> Geophysical M <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ,. H.P. <br /> PUMP REPLACEMENT: /�,,/, —7- <br /> PUMP -REPAIR: <br /> 't"`PUMP .REPAIR: <br /> State- Work Dane <br /> DESTRUCTION OF WELL: We11° Diametefr t A roximate De ' <br /> PP p thj© — <br /> Describe Material. and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District r <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS . <br /> after completion of my workon -a new,well, I will furnish the San Joaquin Local Health District a ' <br /> WELL DRILLERS ;_�t�riuejthe <br /> ORT of twell,: and notify tfem before putting the well in use. The above <br /> information is best of my knowledge: and 'bel'ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT INAL S <br /> SIGNED �'r ' TITLE 451 4 <br /> E DRAW' PLT PLAN 'ON REVERSE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> DATE 3 -.,Z.,,3-7�' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIT FINAL INSPECT .O i <br /> INSPECTION BY DATE INSPECTION BY DATE T <br /> i <br /> E H 1426 Rl. 74 __-376 2M <br />