Laserfiche WebLink
. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> $U&;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 Joaq%An <br /> County Ordinance No. 1862 and the Rules and Regulations of thee San Joaquin Local Health District:: <br /> JOB ADDRESS/LOCATION S�'� � --d 1�- CENSUS TRACT <br /> Owner's Name Phone <br /> Address j—zp-a City <br /> Contractor's Name icense # Phone --� <br /> Q22,142 AQ&2Z&9� <br /> TYPE OF WORK (Check): NEW WELL. /? DEEPEN '/7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION/7 PUMP REPAIR'/ PUMP REPLACEMENT <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 SIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> t--- Domestic/private F-Drilled Dia. of Well Casing <br /> ' Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal sZ <br /> Cathodic Protection -Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BX: <br />`PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPIREPAIR: /7State Work Done <br /> OG/i✓fF,e 7p �ADVFj2Ly 'f4ghNi>Approxima a Depth • <br /> ES�TRUCTION OF WELL Well Diameer <br /> Descrihe ..Nx.terial 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 TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <5 M TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE ' S,23 77 <br /> ADDITIONAL COMMENTS: <br /> I ROUT INSPECTION P I F SPECTION <br /> INSPECTION HY,, DATE y//,) 7 7 INSPECTION BY DATE �-- (— -7 <br /> _s Zs ff <br /> 3 JR n.�l1 <br /> E $ 1426 1-74 h/75 9M <br />