Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOBrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76 //7J10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /.2 <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 Vl f ie n E ,t o h,- t��'LG►�"b A) S. CENSUS TRACT <br /> o e- <br /> Owner°s Name �-��, �q ,,� jj _ Q{� Phone 2 960 <br /> Address /.5�i V)A ul f.L 5 A VLs City . ksc 1ak.oz� <br /> Contractor's Name j, eQ, in.—r. .J License Phone FA:aa0l <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR /-7 PUMP REPLACEMENT /f <br /> 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 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 Cli <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 Serial Installed BY: <br /> PUMP INSTALLATION: Contractor l7 ./ <br /> r � <br /> Type of Pump H.P. d <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> XS1RUCTION 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UTING AND AQFINAL INSPECTION. <br /> SIGNED , TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . IDATE 1 )-3Q-2( <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI - PHA I I INSPECTION <br /> INSPECTION BY DATE INSPECTION BYILZy ' DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />