Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO _f} !CE USE: 1601. E. Hazelton Ave. , Stockton, Calif. �. .N <br /> fi" Telephoner (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 h�Eeby 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 /> a <br /> JOB" ADDRESS/LOCATION L o tit e�1 �: �"ffo.a_�%a G' CENSUS TRACT <br /> Owner's NameL B cqT Cr4 f Tib Phone <br /> I <br /> Address f? 0, ffox g'Qq City ;r1.1&AA110A( <br /> Contractor's Name +! I"LSa,95 License #)991_7 /Phone <br /> TYPI� OF WORK (Check) : NEW WELL /DEEPENr—,/ / RECONDITION [—/ DESTRUCTION /-7 <br /> E. PUMP INSTALLATION /vI PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES p PIT PRIVY —_• <br /> ± SEWAGE DISPO A�F-IELD 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 /> i <br /> �+ Domestic/public Driven Gauge of Casing 210) <br /> !; Irrigation Gravel Pack Depth of Grout Seal * r <br /> Cathodic Protection ' Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor nSjj <br /> C �„ <br /> i€ Type of Pump ---��.- bi --, i H.P. . <br /> �f - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> 11 f9 <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"constructi.on. Within FIFTEEN DAYS <br /> affer. 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 AN FINAL INSPECTION. <br /> SIGNED TITLE <br /> II ' (DRAW PLOT PLAN ON REVERSE SIDE) <br /> !" FOR DEPARTMENT USE ONLY <br /> PHASE I '' r <br /> 17 <br /> APPLICATION ACCEPTED BY E DATE <br /> } ADBITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4t, DATE <br /> 6/77 2M <br /> 1!E H 1426 Rev. - I-74 � <br />