Laserfiche WebLink
jdd SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE:OFFICE USE: J 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466--6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 38a tJ <br /> 71° � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued A- <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/LOCATION10 <br /> L-� Lq= / <br /> CENSUS TRACT <br /> Owner's NamePhone a :?no---�=-- I <br /> Address City <br /> Contractor's Name .11puse #A�Phone <br /> TYPE OF WORK (Check): NEW WELL "/�DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /Lk-;PUMP REPAIR-/-7 PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANKS 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 7� �� ,1� �' � 1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Drives Gauge of Casing /10 q <br /> �rrrigation Gravel Pack Depth of Grout Seal ,.„..., <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal _ Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump dr.P. <br /> PUMP REPLACEMENT: , / State Work Done \ r <br /> PUMP .REPAIR: /7 State Work Done r �* <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 "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 D A F NALS CT `J <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN Old REVERSE SIDE <br /> PHASE z FOR DEPARTMENT USE ONLY <br /> APPLICATION' ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I G OUT SPECTION PHA6SE Atf/FINPA INSPECTION <br /> INSPECTION BY TW INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 S r h/75 2M <br />