Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone : (204) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> r <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued ('/y <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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> k JOB ADDRESS/LOCATION .OaB f OF S �jyjp CENSUS TRACT013-7-30-12- <br /> - . . <br /> Owner's Name f},tID /A/ P Phone 56p 7-79 S'O _. <br /> Address 02� . <br /> G%� - � D city _/Ic,*o"�' <br /> Contractor's Name License QeZ--Phone <br /> ' r <br /> A <br /> i TYPE OF WORK- (Check) : NEW..WELL DEEPEN %/ RECONDITION / / DESTRUCTION <br /> �- PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / / �.�.., �n• <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ] <br /> SEWER LINES <br /> SEWAGE DISPOSAL FIELD CESSPO 1SEEPAG FIT OTHER <br /> PROPERTY LINE SOPRIVATE DOMESTIC WELL WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �� Cable Tool Dia, of Well. Excavation /72-j-1 <br /> Domestic/_private- <br /> Dome•stic1public --Driven-- <br /> Irrigation <br /> -Driven —Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: A/ / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> • DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> a Describe Material and Procedure <br /> I hereby agree to comply with all Jaws and regulations of the San Joaquin Local Health District <br /> ',.-and')the State of California. pertaining to oryregulating well. 'construction. Within FIFTEEN DAYS <br /> afterjcompleti%6n of my work on a new well, I gill 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 knowledge and belief, I WILL CALL FOR A GROUT INSP CTION <br /> PRIOR TO GROU NG AND; A FJ:NAL INP T ON. <br /> SIGNED a TITLE <br /> og <br /> ,• (DRAW PLOT PLAN ON REVERSE SIDE) <br /> t FOR DEPARTMENT USE ONLY ., <br /> ..,PHASE I ,�' <br /> APPLICATION ACCEPTED,�BY ;r r ,� DATE i <br /> ADDITIONAL COMMENTS: <br /> :E �.!'C,_L ASE_ff;ZROUT_ INSPECTION. 1a� PHASE III/FINAL INSPECT ON <br /> INSPECTION, BY - DATE INSPECTION BY /", DATE� <br /> �•. <br /> r 2M <br /> E H 1426 Rev. .'1-74 <br />