Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: C� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � a 9lJ <br /> 77-a S6� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z-IT-27 <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 �a-trr�J �j CENSUS TRACT <br /> Owner's Name's a`\ �. Phone �a <br /> 3 � _ <br /> Address � � City <br /> Contractor's Name �� License 4V6_1,3 7373 Phone, ti . s <br /> 1IF <br /> i' <br /> TYPE OF WORK (Check) ; NEW WELL DEEPEN '/—/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION .4<I PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other l <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY { <br /> SEWAGE DISPOSAL FIELD �� CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL Z92 PUBLIC DOMESTIC WELL <br /> __. INTENDED USE _ _ -..TYPE ,OF -WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing , <br /> Domestic/public Dri�en'� � ' Gauge. of Casing- <br /> rIrrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I>(_ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal ..Installed By: W"n=e.,j <br /> PUMP INSTALLATION: Contractor .� f <br /> Type of Pump <br /> H.P. <br /> - ---- .— <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 of the well and notify them before putting the.-well in use. The above <br /> information rue to the est of my. wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G U NG D AL INSPECTION. <br /> SIGNED TITLE <br /> la4DRAW PLBT PLAN ON REVERSE SIDE)f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ^� <br /> APPLICATION ACCEPTED BY DATE ?- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE <br /> IPJILNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY (J�l,,�,.g DATE <br /> E H 1426 Rev. 1-74 3/76 2m <br />