Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR"OFF-ICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone : (209).. 466-6781 y7�-3(0 0 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <br /> THIS:PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue AR <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 compl.iance. with .San Joaquin : <br /> County Ordinance No. 1862 and !the Rules. and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION d( e'r CENSUS TRACT <br /> _ <br /> Owner's Name Z 0.7 /_tom' 'hone <br /> Address + �' I�a7 Pr City / Ci D�-- <br /> Contractor's Name [ �{ License �VAz1 -Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION f_1 DESTRUCTION /_7 <br /> PUMP IiSTALLATION / / 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 I//=Cable Tool Dia. of"'Well Eacavati.on F <br /> __A!nn-Domestic/private i Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ! : Gravel Pack Depth of Grout Seal <br /> Cathodic Protection } Rotary =-- - -Type.o-f Grout <br /> Disposal. I ,- Other Other Information <br /> Geophysical Surface Seal' Installed By: ,, <br /> t� <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump H.P. _ f <br /> J+ 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 <br /> Joaquin Local Health District <br /> a <br /> I herebyto with all flaws anal_ regulations of the San Toa q <br /> gree comply P y <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--W'Ill 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 FIN L_ SPECTION. <br /> t SIGNED TITLE f /� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> _- FOR -DEPARTMENT USE -ONLY <br /> PHASE I , I . <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> P S I GROUT INSPECTIO PHA I /FINAL INSPECTIO <br /> INSPECTION"-BY _ta. - DATE . .a" rT� INSPECTION"BY_ _ r -r-DATE <br /> 677 - 2M <br /> E H 1426 Rev- 1-74 '�` <br />