Laserfiche WebLink
SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR-OFFICE USE 1601 E. Hazelton Ave., ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> Or <br /> APh CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Z4I <br /> ( _I �, THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S <br /> —I ,LIJ� (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 Joaquiu <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> P e <br /> JOB ADDRESS/LOCATION OV138 CENSUS TRACT <br /> Owner's Name jA <br /> tMWPhone <br /> Address �s �� C - City' f <br /> Contractor's Name License #a&ZZ Phone� S <br /> TYPE OF WORM. (Check): WELL /? /RECONDITION /? EN <br /> DESTRUCTION /? <br /> PUMP INSTAL / / PUMP REPAIR / PUMP REPLACEMT <br /> Other <br /> DISTANCE TO NEAREST: =SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE MMESTIC WELL PUBLIC DOMESTI <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI <br /> Industrial Cable Tool Dia. of Well Excavation - <br /> t_ Domestic/private Drilled Did. 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 40ther Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP I,LiSTALLATION Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP PAIR: /% State Work Done <br /> DESTRUCTION a Well Diameter t/-( ` r jam . mate Depth �y <br /> De cribe Mater3�al an4 Procedure <br /> I hereby agree to comply with all laws and regulatiefis of the an Joaqu n Local Health DIstivet <br /> and the State of California pertaining to or regulating well'•cou$truction. 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 FeivIt i TITLE <br /> (RRAW, P PLAN ON j RSE SIDE , <br /> FO EPARTMENT USE OnY <br /> PHASE I <br /> APPLICATION ACCEPTED BY U, DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSP CTIO PHA II NAL INSPECTION <br /> INSPECTION $Y DATE INSP4CTION BY DATE <br /> ��(� <br /> E H 1.426 Rev. 1-74 1;2cGf�� ? 1/7.7 - 29 <br />