Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i Tele he : (209) 466--6781 <br /> P 'on <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 7 7.. <br /> N !� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,. l_ .�_-_]-] <br /> (Complete In Triplicate) 7 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the workherein 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 /> k `:2SSs.O • E,_. ,Q EG 1C A�0 # �� 22-7- 630- If <br /> JOB ADDRESS/LOCATIONS tz r.,c t - ry a +D",c i CENSUS TRACT <br /> F <br /> ,p <br /> ! Owner's Name �R M ib /�� PA�t t2-.Lz _ - Phone 3 " d2 <br /> r �R <br /> Address ' (-r <br /> City P__*7-e . <br /> Contractor's Name i!�`t f1 5.4 cti.f License d E Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /7 _ <br /> PUMP INSTALLATION _/G_ PUM}' 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 f11 <br /> ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Z,- Domestic/private.;E Drilled Dia, of Well Casing <br /> vDomestic./_pub-lic_-4 ---Driven--- --- -l--Gauge -of=Casin°g- <br /> Irrigation Gravel Pack :} Depth of Grout Seal <br /> TCathodic Protection Rotary -- - --Type..of.-Grout•- - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> X <br /> PUMP INSTALLATION: ii Contractor 1 <br /> i;Type of Pump S'v H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: '`Well Diameter Approximate .Depth <br /> eLr 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 mywork on a new well, I will furnish the San Joaquin Local Health District a <br /> G WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> i4 information is true to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN AND A FINAL INSPECTION. <br /> SIGNED TITLE/E) <br /> �.r +-- <br /> � (DRAW PLOT PLAN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> :r <br /> ADDITIONAL COMMENTS: ii <br /> PHASE II g%UTANiVECTION PHAS I/FIML NSPECTI N <br /> INSPECTION BY DATE Aj INSPECTION B DATE <br /> 2M <br /> E H 1426 Rev. - I-74 <br />