Laserfiche WebLink
SAN J'OAQUIN LOCAL HEALTH DISTRICT <br /> FOVOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a Q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1--11L ; <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 /> // t <br /> .TOB ADDRESS/LOCATION �O 6 CENSUS TRACT <br /> Owner's Name Phone f gl - <br /> Address <br /> city <br /> Contractor's Name �j ` <br /> C ' �!� License # Q/QPhone , <br /> TYPE OF WORK (Ch ck): NN ,WELL '[ / DEEPEN /% RECONDITION /% DESTRUCTION /_ <br /> _ .__.._.._-_P_UMP...INS.TALLAT.ION_/ / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER M <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 Diva. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Graved Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout Q <br /> Disposal Othefj Other Information _ <br /> Geophysical 3 Surface Seal Installed B --- <br /> PUMP INSTALLATION: Contractor' ` <br /> Type of ;Pump H.P. i <br /> PUMP REPLACEMENT: State Work Done �� e <br /> JF <br /> PUMP .REPAIR: / / State Work Done C <br /> DESTRUCTION OF WELL: Well Diameter r Approximate Depth <br /> Describe Material and Procedure 4 <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 <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 FOR A GROUT INSPECTION <br />?RIOR TO GRO G AND A F NAL j4spON. 0, V i <br /> SIGNED TITLE 96 <br /> /-(D&AW PLOT PLAN ON REVERSE SIDE) , <br /> FOR DEPARTMENT USE ONLY z'+ <br /> PHASE I F <br /> APPLICATION ACCEPTED BY DATE F4 <br /> ADDITIONAL COMMENTS: <br /> PHASE I1/,RSP CTION F S I/FI AL .I SPECTIqN ' <br /> INSPECTION BY DATE INSPECTION BY DATE 1) <br /> IV <br /> E-H__1426 PP.7_ , 1-7L Y or�77 �tw l� <br />