Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FG03FICE USE: r 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ' S"-�-t/ <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 3(-/7- .,4 - CENSUS TRACT <br /> V <br /> Owner's Name Phone <br /> Address 1 C? o ry City 727&;tom <br /> Contractor's Name Ifeen� W n7iin ger n c,, T)r i l�lri n�C,n— ,T n e- License # p� 3 Phone Kp p_ i <br /> 1. <br /> 2500 _B is l e i'{7�d, f.l � es G.® T AS�ISfCSIIS'�E�I I4�1� <br /> TYPE OF WORK (Check): NEW WELL/,x DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /-7 PUMP REPAIR /-7PUMP REPLACEMENT 17 <br /> Other /7 <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 /> Industrial Cable Tool Dia. of Well Excavation /-I ��• <br /> Domestic/privatei,—Drilled Dia. of Well Casing <br /> v Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal __.. <br /> Cathodic Protection j.,—Rotary Type of Grout <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 /> PUMP :REPAIR: /-7 State Work Done <br /> ES•TRUCTION 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 .AND A FINAL INSPECTION. <br /> SIGNED © 0 Inc. by TITLE , ,,, s e g <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> MAU IjbGROUT INSPECTION PHA I FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE 7s <br /> f E H 1426 Rev. 1-74 1-74 2M <br />