Laserfiche WebLink
'(14'. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFx'OFFICE USE: 1601 E. Hazelton Ave. Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELD.-CONSTRUCTION OR PUMP PERMIT Permit No. 7s-1d41S`/� <br /> THIS PERMIT EXPIRES i YEAR FROM DATE ISSUED Date Issued //-3-,ZS- <br /> (Complete <br /> /3-,S(Complete In Triplicate) �T <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 /> .TOB ADDRESS/X,QCATTON �+.c k�S TRACT <br /> Owner's Name .,S Phone !ZZ]- ©;t a,L <br /> Address City <br /> Contractor's Name License #/4,232-3 Phone <br /> TYPE OF WORK (Check) : NEW WELL.-_0 DEEPEN '/_" RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR/? PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD LaJ" CESSPOOL/SEEPAGE PIT OTHER SCS <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELD,* <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ,x "Cable- Tool Dii. of Well Excavation <br /> Domestic/private Drilled ' Dia. of Well Casing ul <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth. of Grout Seal e <br /> Cathodic Protection Rotary Type of Grout I <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> 6e <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done +, <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 ifornia pertaining to or regulating well.''construction. Within FIFTEEN DAYS <br /> after comple ion of work on new , I will furnish the San Joaquin Local Health District a <br /> WELL DRILLE S REPORT f the w 11 an of fy them before putting.. the-well. in.use.. . The above <br /> information is true the-b st f.. owledge and belief. I WILL CALL OR A GROUT INSPECTION <br /> PRIOR TO GR T :A Fit <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) . ,- <br /> FOR DEPARTi�NT USE ONLY <br /> PHASE I _ t � - ..„ <br /> APPLICATION ACCEPTED BY - DATE <br /> ADDITIONAL COMMENTS: *�,. '"" <br /> PHASE II GROUT INSPECTIONPHA II FIN INSPECTION <br /> INSPECTION BY DATE INSPECTIO1i ;BY DATE <br /> E H 1426 Rev. 1-74 � 4/75 2M <br />