Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 456-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��; <br /> 76�s�lo <br /> THIS PERMIT EXPIRES 1 YEAR PROM DATE ISSUED Date Issued <br /> w (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 CENSUS TRACT <br /> rt <br /> Owner's Name C Phone3 � �f <br /> Address <br /> LL f <br /> � ��� -5-C,. �'G�/' �i_T.�r .��� City. . . _ 1 <br /> Contractor's Name i LicenseW�LWPhone M f_ <br /> TYPE OF WORK (Check): NEW WELL/Lj_P- DEEPEN /7 RECONDITION /? DESTRUCTION f7 <br /> PUMP INSTALLATION / ice REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4--Cable Tool Dia. of Well Excavation r <br /> .n ; <br /> Cinestic/private Drilled Dia. of Well Casing <br /> � <br /> Domestic/public Driven Gauge of Casing _ ITE <br /> i 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 10i <br /> PUMP INSTALLATION: Contractor <br /> + Type of Pump iO H.P. <br /> � •1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> 2ES,TRUCTION OF WELL-.' Well Diameter Approximate Depth <br /> Describe�Material and Procedure <br /> .- <br /> '-, ' <br /> I I hereby-agiee to -comply with all laws and regulations of the San Joaquin Local Health District <br /> 4 dnd the-,,5ta'te of Ca �fornia 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 is -true to the-best of my.knowledge, and belief. I WILL CALL FQR A GROUT INSPECTION <br /> PRIOR TO GRONENGD A FINAL JsKWECTION. ��� <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I. <; , <br /> APPLICATION ACCEPTED f �s-�. y DATE -- <br /> ADDITIONA -' COMMENTS <br /> PHA E II GROUT INSPECTION PHAS ' I I .FINAL INSPECTION <br /> INSPECTION BY TE INSPECTION BY DATE <br /> 5' a 7 - <br /> .� E H 1426 Rev. 1-74 1-74 2M <br />