Laserfiche WebLink
. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE: L1601 E. Hazelton Ave:, Stockton; Calif. <br /> Telephone: " (209) 4661..6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -2,7- <br /> THIS <br /> 7THIS PERMIT EXPIRES 1 YEAR -FROM DATE ISSUEDO Date Issued 6�.�3>> <br /> (Complete ,In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Diatrict 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.fhe' San' Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION $" CENSUS TRACT <br /> Owner's Name p <br /> �' � Phone <br /> Address <br /> K. City c � <br /> Contractor. a Named -1�, r . .p ,�,. License•# <br /> " . _ "'Phone <br /> TYPE OF WORK (Check) : NEW WELL ,/_7 DEEPENRECONDITION /_7 DESTRUCTION 1 <br /> PUMP INSTALLATION / PUMP REPAIR' <br /> / PUME %REPLACEMENT 17 <br /> 4.. Other /_7 �.' <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> `5LWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PIT OTHER , <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL- PUBLIC DOMESTIC WELL <br /> .INTENDED USE TYPE OF WELL CONSTRUCTION .SPECIFICATIONS <br /> Industrial g <br /> �.. !i.' Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled I Dia. of Well Casing <br /> ;Domestic/public Driven Gauge of Casing <br /> ;Irrigation �_ }Gravel Pack DepthType Gr'out,Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal .3 Other- Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMVINSTALLATION: Contradtor : <br /> r 40- '42v AdA <br /> ,Type'-of a PU4 H.P. <br /> - <br /> PUMP REPLACEMENT: E17 State Work Done4 <br /> PUMP',REPAIR:s.. -- -- -State-Work-Done } <br /> E&TRUCTION OF WELL: Well• Diaeter t Approximate Depth <br /> Describe katerial'and Procedure <br /> 1 <br /> I hereby agree to comply with all laws Arid 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,y } <br /> .SIGNED '�- _ � TITLE <br /> ---(DRAW-PLOT"PLAN-ON 4R VERSE SII3 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ;� Z-31171 -17 <br /> ADDITIONAL COMMENTS: t z1z <br /> PHASE II GROUT I SPECTION` PMME XXUFI AL INSPECTION <br /> INSPECTION BY DATEINSPECTION BY DATE 3/ 28' <br /> i E H 1426 Rev. 1-74 <br /> 1_7 A jM <br />