Laserfiche WebLink
<p �c `i'Ite- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFIC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -IP2' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L/�=7 <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 g�� / �a CENSUS TRACT <br /> Owner's Name 'g, 11 f/, cos azc) - Phone <br /> Address OG / S `r, , �-�c1 _ City <br /> Contractor's Name License # 7Y1 Phone ! L S <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP 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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Q <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 <br /> Seal Installed By: <br /> PUMP INSTALLATION: Contractor , SCJ <br /> Type of Pump H.P. y <br /> PUMP REPLACEMENT: / State Work Done <br /> -- -- <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 ,is true to the best o_f my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING AND A FINAL I SPE <br /> SIGNED TITLE <br /> 7(DRAW- PLOT PLAN 'O"EVtRSE SIDE <br /> R TMEN USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED / ( U6 L /�/ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 _ /7b 2M <br /> Rev. 1 74 <br />