Laserfiche WebLink
/ lGr� A 4W SAN JOAQUIN LOCAL HEALTH DISTRICT � <br />/ <br /> t FOE OFFICE USE: 1601 E. Hazelton Ave. ,. Stockton, Calif. <br /> 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�a' - <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 /> JOB ADDRESS/LOCATI.ON `2 8 S wnCENSUS TRACT <br /> Owner's Name K- 6 f--rL Phone <br /> r � - . <br /> a Address. City _ <br /> Contractor's Name License # 224 Phone e1_G y '7 ]lb/ <br /> I, TYPE OF WORK (Check) : NEW WELL / / DEEPEN %/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR _12q PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL- PUBLIC DOME5TIC WELL \ <br /> INTENDED USE TYPE` OF WELL CONSTRUCTION SPECIFICATIONS CSI <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 Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION:z <br /> Contractor -•--- <br /> Type of Pump sSu. /a .rrr a ✓. ?► A H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / State Work Done <br /> � u <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 thewell 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 INSPIQCTION^. (�] { <br />. -SIGNED �""'� - 4TITLE d f <br /> (D1WCfff6T PLAN OX- REVERSE SIDE) ! <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /d -OL -27 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE SPECTION <br /> INSPECTION BY DATE 4 INSPECTION BY DATE <br /> E H 1426 Rev. - l-74 2M <br />