Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT l <br /> FOE':OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No -2— ' <br /> 7- 7 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued' <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 <br /> the Rules and Re u tip �g of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION :P Va,2 3 �� mac( CENSUS TRACT <br /> Owner's Name 1 Phone 3an-- 77 <br /> AddressADB Z - 2 a3zn/ City ` <br /> ... - -License -#, <br /> Contractor's Name <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_ RECONDITION /__/ DESTRUCTION /_ <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK lafP SEWER LINESi PIT PRIVY C7 ; <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,,X3,951e Tool Dia. of Well Excavation RW Z <br /> ��omestic/private Drilled Dia. of Well Casing 6 <br /> Domestic/public Driven :,Gauge of Casing <br /> - Irrigation -Gravel PackL of Grout Seal_ -� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical -'Surface Seal Installed By: '�, <br /> s� <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: / t State Work Done L-2 e2717. <br /> PUMP .REPAIR: / / State Work Done <br /> r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure s , . <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 .wel.l�eonstruction. t Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the,,San Joaquin total Health District a <br /> WELL DRILLERS REPORT of the well and notify them befoxe put tingthe..well in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN A FINAL INSPECTION. �� 1 <br /> SIGNED _- w.TITLE,....._ � <br /> DRAW PLOT -PLAN-ON }?,EVERS•E SIDE) <br /> k FOR DEPARTMENTkUSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY < ' L71 DATE4iwl <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE//'��• <br /> X1772M <br /> E H 1426 Rev. 1-74 --- <br />