Laserfiche WebLink
F' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> O$,rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466- <br /> 6 <br /> APPLICATION FOR WELL CONSTRUCTION 0R1PUMP 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 :Wade 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 7545: E. Southland Road <br /> CENSUS TRACT <br /> Owner's Name Raymus Real Estate & Ins., Inc. 823-3148 <br /> Phone <br /> Address . 544 E. Yosemite Avenue <br /> City Manteca <br /> Contractor's Name l <br /> License 062?l/ Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / ' RECONDITION /7 DESTRUCTIO <br /> N f7 <br /> PUMP INSTALLATION ./ / PUMP REPAIR <br /> Other f/% /_7—Pump REPLACEMENT `] <br /> DISTANCE TO NEAREST; SEPTIC TANK <br /> SEWER LINES PiT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INDED USE PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELLT�� <br /> NTETYPE OF WELL CONSTRUCTION SPECIFICATIONS V <br /> Industrial Cable Tool (� <br /> � ;•�.. Dia. of Well Excavation <br /> Domestic/private <br /> Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation t ` Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 i--Rotary Type of Grout <br /> Disposal - i y Other { <br /> Geophysical - Other InformationI <br /> Surface Seal. Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT; / IT State Work Done �• <br /> PUMP :REPAIR: <br /> / 7 State Work Done 43 <br /> ES:TRUCTION OF WELL: Well Diameter <br /> DescriSe Material and Procedure Approximate Depth <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 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 UTING AND FINAL INS ECTION. <br /> SIGNED <br /> TITLE <br /> DRAW LOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY i <br /> ADDITIONAL COMMENTS: DATE <br /> x <br /> P E GROU NSPECTION P Ej1I FINAL INSPECTION <br /> INSPECTION BY DATE - -1� INSPECTION BY :x <br /> � n n� DATE <br /> E H 1426 Rev. 1-74 <br />