Laserfiche WebLink
f ' <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOS OFFICE USE: 7.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. e7,0 4/ <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ,ISSUED Date Issued <br /> (Complete In Triplicate) <br /> i 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 /> E JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> f Owner's Name Phone ��l..r�"247'V <br />'k Address _ , ice —.,,. City <br /> Contractor's Name License # '=471- Phoney,?-�'"`gf <br /> TYPE OF WORK (Check):T NEW WELL 'DEEPEN '17 RECONDITION /7 DESTRUCTION f'7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/� PUMP REPLACEMENT /7 <br /> Other <br />, .DISTANCE TO NEAREST: SEPTICi.TANK (/ SEWER LINES PIT PRIVY <br /> SEWAGE ?DISPOSALTIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE = PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE <br />� TYPE OF WELL CONSTRUCTION SPECIFICATION <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 T. Gravel PackDep Ch-of Gz�o <br /> ut-`Sea7 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal <br /> 4 Other -_-..._ Other Information <br /> Geophysical` ; Surface Seal installed 'B : <br /> PUMP INSTALLATION: Contractor C.. <br /> Type .of"Pump $. H.P. <br /> PUMP REPLACEMENT: ' /7 State Work Done <br /> PUMP .REPAIR: r <br /> / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> . - 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' pertaining4to or regulating well''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new we11'.. 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 T U NG A F NAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON. REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY��j - DATf <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTION PHA AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 6 <br /> 2 G <br /> E H 1426 itun_ 1-74 r �. �wr .,r„-�' <br />