Laserfiche WebLink
j� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. ; Stockton,-Calif. <br /> Telephone: (209) 466-6,781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP .PERMIT Permit No. -7 -W <br /> THIS PERMIT EXPIRES 1- YEAR FROM DATE ISSUED Date issued <br /> .A IN(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 Joaquin <br /> County Ordinance No. 1862 and the Rules. and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION wf e .5 cZcfiJfWA P4, .�___vf1kf - e+ 9 /eon�CENSUS TRACT. <br /> Owner's Name o co <br /> Phone R 'L� <br /> Address F A ,,,t City c !'r 7r ev . <br /> ji <br /> Contractor's Name r.X0.0f4 License #A65 761 PhoneEr 011 <br /> (�y <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION -./-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / /,� Pi}MP REPLACEMENT <br /> Other / / J. ` <br /> DISTANCE TO NEAREST: SEPTIC TANK r 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 /> Domestic/private Drilled Dia. of Well Casing <br /> � j <br /> -Domestic/public Driven Gauge of Casing <br /> L_— Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ;o Other Other Information = Ar <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of .Pump H.P. <br /> „ .R <br /> PUMP REPLACEMENT: State Work Done r o <br /> PUMP REPAIR: /.i / State Work Done <br /> I� <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 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 HealthiDstrict 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 INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> iy <br /> APPLICATION ACCEPTED BY 'i' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHAS III/ INAL INSPECTION E <br /> INSPECTION BY ;I DATE INSPECTION BY DATE7P- - <br /> ro; % 2M <br /> N , E H 1426 Rev. , 1-74' <br />