Laserfiche WebLink
n SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fo_iZFFICE USE: 1601"E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76 <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 /> owner's Name-.' Czq YC W,e-) Phone ' <br /> Address 3 41 Z f IP City '-S G dr` La <br /> Contractor's Name C A ZZ& wl" ,L A t 0 U ] 4 <br /> �'� License � ���.� Phone �.�" j <br /> TYPE OF WORK (Check): NEW. WELL /_'� DEEPEN -/-7 RECONDITION /7 DESTRUCTION f <br /> PUMP INSTALLATION/ / PUMP REPAIR'/� PUMP REPLACEMENT f <br /> Other / J <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 . t Cable Tool Dia. of Well Excavation �j <br /> Domestic/private Drilled -Dia. of Well Casing _ <br /> Domestic ublic " `Driven a e Gau of Casing <br /> /p ' g , . <br /> IrrigationGravel Pack Depth of Grout Seal a <br /> Cathodic Protection Rotary - Type of'-Grout' <br /> Disposal Other Other Information'. <br /> Geophysical x Surface Seal Installed 'By: <br /> (PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: . / / State Wo <br /> PUMP .REPAIR. / e Wprk O / L <br /> DESTRUCTION-_OF W L: f ICameter A proximate Depth d <br /> Descr be Material and Procedure - - <br />. ��� - -. <br /> I hereb ag a to mply with law 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 /> j 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 FORA GROUT INSPECTION '.. <br /> PRIOR TO TI .G A F AL INSPECTION. <br /> SIGNED f TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> E FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION'ACCEPTED BY DA IlO <br /> ADDITIONAL COMMENTS: <br /> PHASE II 2R0 SECTION PHA NSPECTION <br /> INSPECTION BY LZATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 r <br />