Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F—FOF .OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> c Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .,Z-A-71- <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 /> � i r <br /> JOB ADDRESS/LOCATION 539X AN G,'�( pat CENSUS TRACT <br /> Owner's Name MAR Ll 0 Q I I Let Phone — g <br /> Address A) City <br /> Contractor's Name License #�'���'Phone M_2S= <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION. / <br /> PUMP INSTALLAFTION J PUMP REPAIR / PUMP REPLACEMENT /_7 <br /> Other J / �' -Q% <br /> Vj <br /> DISTANCE TO NEAREST: _ SEPTIC TANK SEWER LINES <br /> PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE'- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL g <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS y, <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private _. Drilled Dia. of Well Casing <br /> Domestic/public -- Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic fProtection Rotary _Type of Grout <br /> Disposal Other Other Information <br /> _Geophysical----"'— - Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump I AO R_ � <. b H.P. 40 ^_ <br /> PUMP REPLACEMENT: / / State Work Done <br /> E '* <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION 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 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. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE I G � . <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I /,FINALINSPECTION - <br /> _ / <br /> INSPECTION BY DATE INSPECTION BY ATE Z,/;r <br /> E H 1426 Rev. 1-74 5 - C>1- '06", ' 117.7 - 2M <br />