Laserfiche WebLink
re <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOArOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 � <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applicidtion is hereby made to the San Joaquin Local Health District for a permit to construct <br /> end/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 /> � _ r <br /> JOB ADDRESS/LOCATION �1& l�r� Sm �-r4�'�' y &do JAI �* CENSUS TRACT <br /> Owner a s Name 11 0tjA&.Q Th 1 o iii IV_-16N _ Phone <br /> Address a <br /> City <br /> Contractor$s Name �� .S�40", � Y'�License # C �O/b Phone � y7 <br /> Check NEW WELL /7 DEEPEN /-7 RECONDITION -/-7 DESTRUCTION /-7 <br /> TYPE OF WORK (Check) _ <br /> PUMP INSTALLATION / PUMP REPAIR /7 PUMP REPLACEMENT <br /> Other / T I&kmi 1 4 f L <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 /> a - Dourest#ic/private -Jk . Drilled -A Dia. .of Well Casing <br /> Domestic/public t A Driven; Gauge of''Casing <br /> ..:� # <br /> 'Irrigation _ Gravel Pack Depth of Grout Seal <br /> I 1 t <br /> �� Rotary,C, Type of Grout <br /> � Cathodic Protection Rotary � yp <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed- By: <br /> PUMP INSTALLATION: Contractor 1 i <br /> Type of Pump H.P. t <br /> t <br /> PUMP REPLACEMENT: j—/ State Work Done <br /> PUMP".REPAIR: /? State-Work Done <br /> ��� z <br /> CIES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> . T <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 /> I information is txue to--the best--of- my=.knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> M PRIOR TO OUTING AN A INAL INSPECTION. <br /> SIGNED TITLE <br /> ` ON <br /> DRAW PLOT PLAN REVERSE SI E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3D-7U <br /> ADDITIONAL COMMENTS: <br /> PHASEjII<GROUT INSPECTION P SE INSPECTIO <br /> INSPECTION BY v7777 <br /> ,' ' DATE _' INSPECTION BY DATE <br /> M1 - <br /> 14, E H 1426 Rev. 1-74 1-74 2M <br />