Laserfiche WebLink
SAN JOAQVIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: /"' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 <br /> 0ePe, OF br el good - gmik e to, aA/I,00aCENSUS TRACT <br /> Owner's Name d �.QZ � � ��,a,,i/ PhonejQ"-- 71i <br /> •--- - -- - <br /> Address 7 SO V-a v A l ke ra n d. �. - City f.SCA /c <br /> i <br /> Contractor's Name rWt R �rL 5���-t1 �- �`�.+ _�1.C•� �.�_� License # Phone <br /> TYPE-OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION kms} PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER J. <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 r <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing l <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection : Rotary Type of Grout v <br /> Di§posal Other Other Information V <br /> Geophysical Surface Seal Installed By: <br /> ~PUMP INSTALLATION: Contractor 11 [ A 4 ��' ' <br /> r <br /> Type of Pump H.P. "M r <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 t <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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above 1 <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIOIJ <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE . <br /> DRAW. PLOT PLAN ON RE ERSE SIDE <br /> FOR DEPARTMENT USE ONLY l <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> 1 <br /> R__fl <br /> ADDITIONAL COMMENTS: <br /> PHASE II COUT INSPECTION PHAV7IIMIN,4L INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 11DATE <br /> E H 1426 Rev. 1-74 3/76 214 <br />