Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4,?&j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . Date Issued Z-2L-572 <br /> p <br /> (Complete In Triplicate) <br /> Application is Hereby made to the San Joaquin Local Health District far 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/LOCATION D p p L CENSUS TRACT <br /> Owner's Name Phone '��,5" �320 <br /> Address a <br /> � City <br /> Contractor's Naas <br /> Licensefie <br /> es Phone <br /> TYPE OF WORK (Check): NEW WELL 'Jg DEEPEN ' ? f RECONDITION % DESTRUCTION <br /> PUMP INSTALLATION / ( PUMP REPAIR/7 PUMP REPLACEMENT <br /> _ 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER'. <br /> PROPERTY LINEADPRIVATE DOMESTIC WELL PU$LIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ICable Tool Dia. of Well Excavation p <br /> _Z<, Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 2 <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: dccL i <br /> PUMP INSTALLATION: ' Contractor } <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: Ll State Work Done F 1 <br /> PUMP 'REPAIR:.' /_7 .State Work Done ' <br /> ff i <br /> DES:'TRUCTION OF WELL: Well, Diameter <br /> Approximate Depth, <br /> € Describe Material and Procedure A <br /> T 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 `constructibn. Within FIFTEEN DAYS <br /> after completion of my work on anew well, I will."furnish the San Joaquin Local, Health District a' <br /> WELL DRILLERS REPORT of th and notify them before putting the.-well in.use... .Thelabove <br /> information is to a-bes of k;�5 dge, and belief. : I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTI INAL INSPE IO <br /> SIGNED ---'TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE .. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IE <br /> APPLICATION ACCEPTED BY i DATE <br /> ADDITIONAL COMMENTS: ; <br /> PHASE II-GROUT INSPECTION-,..v PHASE' III FINAL INSPECTION <br /> INSPECTION BY DATE -z- 2 . INSPECTION BY DATE <br /> E H 1426 RQv_ 1_77. ^Is <br />