Laserfiche WebLink
SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> FORiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT hermit No. <br /> THIS PERMIT EXPIRES 1l-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 /> JOE ADDRESS/LOCATION CENSUS TRACT <br /> Owner°s Name is , ' _ J LS .... . Phone <br /> Address A.. City AZ <br /> a <br /> Contractor's Name , License ��' ;3 Phone ; <br /> 1 <br /> TYPE OF WORK (Check): NEW WELL 'DEEPEN/7 RECONDITION /_7 DESTRUCTION <br /> �, -- PUMP---INSTALLATION :/ '/ r-REPAIR-1- -PUMP'REPLACEM1NT 1_7 'gyp <br /> Other <br /> DISTANCE TO NEAREST:y SEPTIC TANK --300 LINES --300 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 if <br /> Domestic/private Drilled Dia. of Well Casing i <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ,X Rotary w'� Type of Grout e,�,E wry �- <br /> Disposal Other Other Information > <br /> Geophysical 'Surface Seal Installed By. I ��C* <br /> PUMP INSTALLATION: Contractor <br /> Type of Pum .. ,..,. .,_._3....... <br /> o <br /> yP p SSGy . , ...,,.. H.P. .. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: r /7 State Work Done '" 4"" <br /> 4ES TRUCTION OF WELL: Well Diameter Approximate_ Depth <br /> Describe Material and Procedure <br /> 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 �c'nstriiitiion. Within FIFTEEN DAYS <br /> �' k <br /> after comp3ktion of my work an a new well,. I will .fuz-�nish,-the,:Sa-,n�Joagisin..Local Health -District a <br /> WELL DRILLERS REPOR' of the well and notify _them..before putting the,.well in.use.. The above <br /> information is true to the.best-of my-k-6 iwledge"and Velief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUZI34G AND.4A FINAL INSPECTION,. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE i <br /> FOR .DEPARTMENT USE ONLY q <br /> PHASE I <br /> APPLICATION ACCEPTED BY l � .. DATE 'Z _7� <br /> ADDITIONAL COMMENTS: <br /> PHASE I ROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE �7�7- INSPECTION BY Q; DATE g-77-77.- <br /> -E R <br /> -//--']7_-E.R 1426 Rev. 1-74 -Y^ I_7A Im <br />