Laserfiche WebLink
ter. <br /> = _,f• 44 SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> F .OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1. Telephone: (209) ` 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued M d'7 7 <br /> (Complete In Triplicate) TI <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 gQ �ules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION 61 � S T T <br /> Owner's Name Phone 3 y 7 0 <br /> Address City <br /> Contractor's Name 'A 4 License 53_g Phone - <br /> a <br />,4YPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION /_7 DESTRUCTION /_7PUMP INSTALLATION' PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK fSd SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER q <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation Q <br /> Domestic/private Drilled Dia, of Well Casing 2� �' ,,,__.._ ff"L3, <br /> Domestic/public Driven Gauge of Casing (� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> —.Disposal other Other Information " <br /> Geophysical Surface- Seal Installed B <br /> �w f �t✓fC <br /> PUME INSTALLATION;_ Contractor <br /> Type of Pump H.P. /. <br /> P REPLACEMENT: / / / State Work Done <br /> PUMPrREPAIR: �/ / State Work Done <br /> DES-T UCTION 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 is true to best of nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G ING AND F A INSPE N. <br /> SIGNED — /Z <br /> TITLE <br /> � t <br /> (D W PLOT PLAN 0 FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I H <br /> APPLICATION ACCEPTED $ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 9 TA GROUT INSPECTION PHA,S#AIVI/FIUAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 f fit✓ Gs�*-� � 7� <br />