Laserfiche WebLink
f. SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> g0E �� FICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. t� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 � <br /> T THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued3- <br /> (Complete In Triplicate) <br /> Application is Aereby 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 Distr*ct. <br /> JOB ADDRESS/LOCATION 0600 j WEs I <br /> ZN,F �y M1 So e3 CENSUS TRACT <br /> Owner's Name _2s�L ��1 Phone <br /> Address _ f :�f S- "14 City _4L4 gtI4 <br /> 44 <br /> Contractor's Name T� L,,, �19.bL��LL License Q. p(,Z y Phone 3 .�aw <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/. / RECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / 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 /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing A „,j. A,, i,),r if� <br />_ Irrigation Gravel Pack Depth of Grout Seal c7f---- <br /> Cathodic Protection Rotary Type of Grout — <br /> Disposal Other Other Information <br /> Geophysical ,1 Surface Seal Installed By: _ Al L4 /?4,0,46 <br /> PU14P INSTALLATION: Cretractor <br /> Type of Pump ,,,., 14.P -- <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP -'REPAIR: / / 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 Distxict <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 G OUTING D A F ° <br /> SIN <br /> or. <br /> SIGNED <br /> TITLEk� <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 40 <br /> APPLICATION ACCEPTED BY DATE - y” " f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /_7 z <br /> E H 1426 Rev. 1-74 ��/� 2M <br />