Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE SE: 1 1601 E. Hazelton Ave. , Stockton, Calif. y <br /> 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 ZL/ � <br /> (Complete In Triplicate) r.J ; f� - Z.SU- 12— <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 Sah Joaquin <br /> County Ordinance No. 1862 a d the Rules and Regulations of the San Joaquin Local Health District. . ; <br /> JOB ADDRESS/LOCATION . -8, 9�6Al � � R� 5G � �-� I7r�� CENSUS TRACT <br /> Owner's Name L-S �i Phone <br /> Address .o <br /> d d� City " /Wlr <br /> t a,, 3 T., License # �l Phone4 <br /> Contractor s Name � <br /> L' <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN -/ RECONDITION / DESTRUCTION /? <br /> PUMP. INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /? aQ f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY `} <br /> SEWAGE DISPOSAL FIELD µ 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 <br /> Domestic/public Driven Gauge of Casing <br /> k Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> DisposalOther Other Information <br /> Geophysical •� :: � Surface Seal Installed By: <br /> _. . E.. <br /> PUMP INSTALLATION: Contractor , �J <br /> Type,of',Pump L `" �✓ - H.P. `fin. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Wel 1 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 of- my.knowled e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 02UTING -AND A FINAL AZPE I <br /> SIGNE y TITLE /'� <br /> ]} P LAN 'ON R RSE_ SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I l� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSP TION PHASE III/FINAL INSPECTION <br /> INSPECTION BY �/` DATE <br /> INSPECTION BY --- DATE -- <br /> s 3/76 2M <br /> E H 1426 Rev. '1-74 <br />