Laserfiche WebLink
/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO—RiOFFICE USE: Gt`/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7J 3 Sect <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 BQ the Ru s d Regulations of the San Joaquin Local Health District. <br /> r <br /> JOB ADDRESS/LOCATION ' 01, SUS TRACT <br /> Owner's Name Phone Wz_ 2 OkI <br /> Address. 6 0 city <br /> r Contractor s Name �� License' ,0Q( PhoneZI <br /> YL <br /> .�- <br /> L. <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN'-/_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTAUATION /_1 PUMP REPAIR /-7 PUMP REPLACEMENT f7 <br />,I Other <br /> DISTANCE TO NEAREST: SEPTIC TANK_/�JQ ' -SEWER LINES PIT PRIVY W <br /> SEWAGE bISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTICWELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �- Cable Tool Dia. of Well Excavation V <br /> Domestic/private Drilled Dia. ::of Well Casing P <br /> Domestic/public Driven Gauge•.�of Casing I;Z flame j <br /> ._. <br /> Irrigation Y f, s. Gravel Pack Depth.of Grout Seal <br /> Cathodic Protection ' Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed y: `U <br /> PUMP INSTALLATION: Contractor <br /> f Type of Pump H.P. <br /> 4 PUMP REPLACEMENT: / / State Work Done <br />.. <br /> PUMP .REPAIR: V State Work Done <br /> PES;TRUCTION OF WELL: Well Diameter -_ Approximate Depth <br /> Describe Material and Procedure <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 a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe..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. > <br /> SIGNED } , +_ y - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> _. FOR DEPARTMENT USE ONLY..s— <br /> PHASE I ,� ��-- <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PRASjk II 'GROUR WPION P II F AL INSPECTION <br /> INSPECTION BY / t INSPECTION- BY D 7S� <br /> r <br /> WAD <br /> ,t E H 1426 Rev. 1-74 1-74 ?M <br />