Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOBfWFICE USE: 1601 E. Hazelton Ave- $ Stockton, Calif. <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 1l?/2 <br /> (Complete .In. Triplicate) <br /> Application*�ishhexeby 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.i-1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/,LOCATION . /I I �}q t __F �/ CENSUS TRACT <br /> Owner Is Name _ .V iLU RG�s _ Phone --�� <br /> Address city &A"��a9_ <br /> Contractors Name. _%�S }nj p�- <br /> _ License 01 Phone <br /> V/ <br /> s <br /> TYPE OF WORKS (Choek-,.'N 1-WELLS I7 DEEPEN -/? RECOND ION I? DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / , PUMP REPLACEMENT I=T <br /> F Other /-7 <br /> DISTANCE TO NEAREST: --SEPTIC TANK SEWER LINES ;,PIT PRIVY. <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL e' PUBLIC DOMESTIC WELL <br /> f INTENDED USE TYPE OF WELL j CONSTRUCTION SPECIFICATIONS <br />` Industrial Cable Tool Dia. of Well Excavation: �• <br /> I Domestic/private, Drilled Dia. of Well Casing 1Q <br /> Domestic/public Driven Gauge +of Casing <br /> 'Irrigation Gravel Pack Depth,of Grout Seal <br /> Cathodic Protection Rotary Type of Grout Q � <br /> Dispos, al - - ---fir Oz�ae -�trformation <br /> Geophysical Surface Seal •Ins llgd,B ,:� <br /> PUMP INST,ALLATION:`�-,�,,,\Contra`ctor <br /> M. <br /> ._ - TyeTof. Pump _ H.P. / <br /> a G <br /> «.. f <br /> PUMP REPLACEMENTState Work Done <br /> -PUMP`RE'�i R 1. '" / " '' State-Woik_'Done - <br /> pESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> --- Describe Materia] and Procedure <br /> 1 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-knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> I PRIOR TO GROU G AND INAL <br /> INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL -COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE JIMFINAL INSPECTION <br /> INSPECTION BY _ DATE ;NSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M _ <br />