Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 3j2 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S-FItLC-4fjj,& _yB4j cl _ CENSUS TRACT <br /> Owner's Name 1Ao-1-f ,� 4 ,[ �,� Phone <br /> Address /a �(,h ,.,fd &,ms`sW, City _M4,a:7`ic_ A <br /> Contractor's Name 1)Al, „ e s'h4 12 ctc1SiLl ,a/--17 � License Phone�t��� <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION /24-:'-PUMP REPAIR / / PUMP REPLACEMENT /7 r(� <br /> Other <br /> If <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES ` PIT PRIVY p <br /> SEWAGE DISPOSAL IELD 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 /> t—Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout s <br /> Disposal Other Other Information 4 <br /> Geophysical Surface Seal Installed By: a <br /> PUMP INSTALLATION: Contractor LAZ r f7.r,s,4 <br /> Type of Pump '7°-vR �..� ✓� T H.P. Sly <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 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 CAJL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. �f <br /> SIGNED �.�,. r., �,. 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 III/FINAL INSPECTION <br /> INSPECTION BY I W <br /> .- DATE INSPECTION BY DATE Y <br /> /77 _ 2M <br /> E H 1426 Rev. - 1-74 <br /> n <br />