Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,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 Z9'(,> 5-C, X P6-C, VAL , ,/.� �,�'� CENSUS TRACT <br /> Owner's Name Phone IV- '176.11 <br /> Address :Z„/ Z _ W. 7� J=j'l C�' % �' �'%C' l:1 C d1r' City <br /> Contractor's Name , �. License �� ! ? Phone <br /> .�'' � '' <br /> TYPE OF WORK (Check) : NEW WELL / ( DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 /> Domestic/public Driven Gauge of Casing d Z C'-4, <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotary Type of Grouter ?E-". s'Tfs <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: A104 C K <br /> PUMP INSTALLATION: Contractor 111CAL t-111- /1111 ?f-'1 <br /> Type of Pump c /��' �:'_Si,r 't .E H.P. 1 <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 DAIS <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 FOR A GROUT INSPECTION <br /> PRIOR TO GROPING AND A NAL INSP4CTION. <br /> SIGNED rCTITLE ` , <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 PHASF, III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B ,' , > DATE <br /> E H 1426 Rev. 1-74 117P 2M <br />