Laserfiche WebLink
SAN JOAQUIN LOCAL':HEALTH DISTRICT <br /> I'OR'OFFICE USE: 1601 E. Hazelton Ave. , Stockton., Calif. <br /> Telephone: e-i(20Q) 466-6781. <br /> j APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7- 7 —&) <br /> 72- <br /> HIS-PERMIT EXPIRES' 1D1YEAR:FROM DATE ISSUED Date Issued a-)-,7 <br /> AT <br /> ­(Complete In.Triplicate) . <br /> Application +is her'eby' made to the San Joaquin'.Local-Flealth 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/LOCATION 4. } , n <br /> ,. _. �1 . ''C` 'CENSUS TRACT <br /> Owner's Name ll , , m 6O Y'P ._.,..,_ Phone <br /> Address 2 10J/r �` <br /> _ City � <br /> j . . <br /> Contractor's Namewwkg <br /> License Phone <br /> TYPE OF WORK (Check): NEW WELLDEEPEN /� RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> t \ <br /> DISTANCE TO NEAREST: SEPTIC ITANK ' '' _ SEWER LINES PIT PRIVY �'(J <br /> SEWAGE;DISP SQ AL FIELD CESSPOOL/SEEPAGE PIT OTHER `S <br /> U. <br />'j PROPERTY LINE d PRIVATE DOMESTIC WELI:' ' PUBLIC DOMESTIC WELL j <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial- w Cable Tool Dia. of Well Excavation p <br /> t V Domestic/private t Drilled Dia. of Well Casing K <br /> Domestic/public Driven Gauge of Casing 1,7- <br /> Irrigation <br /> 2Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout' <br /> Disposal Other Other Information <br />'j Geophysical. 'Surface Seal Installed By: _ � <br /> PUMP INSTALLATION: Contractor <br /> Type, of Pump , i H.P;.. <br /> PUMP REPLACEMENT: / / State Work Done _ , -- <br /> State Work,Done-11 <br /> &ES TRUCTION 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 r <br /> 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 ?We1-0Y' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> . ' FOR <br /> D ARTMENT USE ONLY <br /> PHASE I <br /> E APPLICATION ACCEPTED Y L DL-SFIV� DATE. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY /� DATE INSPECTION BYDATE <br /> I <br /> s E H 1426 Rev. 1=74 1-74 2M <br />