Laserfiche WebLink
Y SAN JOAQUIN LOCAL HEALTH DISTRICT ,,� �L - <br /> FOF OFFICE USE; '1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : '(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4 <br /> c <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 -.� CENSUS TRACT <br /> r Vum�oneOwner's Name [j 169_17-36 <br /> - A <br /> Address p CityL /?�- -- <br /> Contractor's Name - License # .22M Phone <br /> t1 <br /> TYPE OF ,W_ORK,,(,Qheck) :. NEW WELL-j DEEPEN ./7/-- RECONDITION- f-1- DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> ` �. <br /> DISTANCE TO NEAREST: SEPTIC TANK I ` SEPTT PRIVY <br /> WER LINES " <br /> SEWAGE DISPOSAL FIELD CESSPOOL'"/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WEI,L PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL i. "-CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia," of`Well Excavation *� ' <br /> I <br /> Domestic/private Drilled Dia. of .Well -Casing pf j <br /> Domestic/public Driven Gauge of-*:Casing i <br /> Irrigation Gravel Pack Depth .of;;e,Grout Seal .- <br /> Cathodic Protection Rotary Type of .Grout <br /> Disposal Other Other Information <br /> F Geophysical Surface Seal Installed_ By <br /> PUMP INSTALLATION- 1 /fit <br /> Contractor / /7 <br /> Type of Pump _?w - - -- - - 11.P. 7-6 <br /> . <br /> PUMP REPLACEMENT: -/ / - State Work Done AIL <br /> PUMP_REPAIR:- - / % State-Werk"Done ` <br /> DESTRUCTION OF WELL: Well,,Diameter '�! Approximate Depth <br /> `Describe Material and Procedure ;5 : t <br /> I .hereby .airee -to.com^p.ly with-..all laws and regulations of the San Joaquin Local Health District <br /> and the State`of California pertaining',no''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 CRO TING AND INSPECTION. i .; 4 <br /> SIGNED TITLE _ <br /> (W14 VLOT PLAN ON VERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY}� '�, DATE <br /> "DITIONAL COMMENTS: <br /> i PHASE II GROUT INSPECTION PHASE IT /FIN INSPECTION <br /> INSPECTION BY DATE <br /> ,"INSPECTION BYI� DATE�1 7� <br />�4 E H 1426 Rev- 1-74 <br /> 0/77�2m <br />