Laserfiche WebLink
_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE 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 <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 ,A nj2 XX Mala hl )a4-doo AV #4 J �,�c"�(l`� CENSUS TRACT <br /> J/' <br /> Owner's Name l kPhone <br /> i <br /> Address Al -,eW CityGaC <br /> Contractor's Name '" License # 7 21,. "phone 4 <br /> til <br /> _ t <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7AL <br /> PUMP INSTLATION / / PUMP REPAIR REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER G <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS1, <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _ >,� 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 f <br /> Type of Pump H.P. 30 <br /> I <br /> PUMP REPLACEMENT: / / State Work Done, r ! <br /> PUMP .REPAIR: /?C/ State Work Done 7- <br /> 01 <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 knowle nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR TING AND A FIN P CT 0 <br /> SIGNED 4< TITLE <br /> W PLOT PLAN ON 1MVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIIZINAL INSPECTION <br /> INSPECTION BY Art M DATE INSPECTION BY DATE jG <br /> ��E H 1426 Rev. 1-74 2M <br />