Laserfiche WebLink
4SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 <br /> � �FORrOFFIGE USE: 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 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit' to construct <br /> and/ 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/LOCATION Q 1 2 CENSUS TRACT <br /> Owner's Name 'OR Lt 6 <-T;f ...� Phone IM � <br /> _ I <br /> Address1 I d/9 devAl., City <br /> Contractor's Name �C L{ L r E J/D �1 j �U. License #A'664 Z Phone a- <br /> TYPE OF WORK (Check): NEW WELD. <bEEPEId /_7- REC4ND TION /_� DESTRUCTION <br /> PUMP INST LATION /—/ -7 <br /> / PUMP REPAIR /� PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ._- SEWER LINES 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.,, rn - --CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation (y <br /> Domestic/private Drilled Dia. of Well Casing . ...,.,.� <br /> /i Domestic/public Driven Gauge of Casing # <br /> g g Z <br /> Irrigation i Gravel Pack ', Depth of Grout Seal <br /> Cathodic Protection Rotary ,,,Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: ,p`*,xe-1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done" <br /> PUMP:`.REPAIR: /-7 State Work Done 6� <br /> ES7RUCTION OF WELL: Well Diameter. �' Approximate Depth <br /> a Describe Material and Procedure <br /> I hereby agree to comply with all lawns 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 GRQ.IJTING ARpA FINAL $PECTION. , <br /> ' <br /> SIGNED / TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 2 <br /> APPLICATION-ACCEPTED-BY, �' ""'�' -"° �" " ` R" <br /> ,. � _...,_..,�--...,.�. - DATE <br /> ADDITIONAL COMMENTS: <br /> PRAW 11 GRO T INSPECTIO14 V PHASE, II /F NAL INSPECT1014 <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 (��-7A ?M <br />