Laserfiche WebLink
SAN JOAQU-IN LOCAL HEALTH DISTRICT <br /> F0T,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zg-az.7&J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/ -7 <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 TRA <br /> �m1J <br /> IT <br /> Owner's <br /> Owner's Name AIL J - - � Phone <br /> Address City , <br /> nn � <br /> Contractor's Name 211 A,d, to License # Phone .- <br /> Lc� 4:1Z 4L24W_ <br /> TYPE OF WORK (Check): NEW WELL /;r DEEPEN /7 RECONDITION /-7- DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR'/7 PUMP REPLACEMENT /? <br /> Other <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 DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria]. Cable Tool Dia. of Well Excavation IN, <br /> k:� _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ /V Rotary Type of Grout 2 ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By-. - <br /> PUMP INSTALLATION: Contractor } <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMPIREPAIR: / / State Work Done . . . <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 TOG UTING AND F INSPECTION, <br /> SIGNED /L t- TITLE <br /> (DRAW P T PL ON REVERSE SIDE <br /> FM DEPARTMENIT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ' /ZZ zzlL_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATES INSPECTION BY DATE -- `Z' <br /> E H 1426 Rev. 1-74 h/75_ _2M <br />