Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$rOFFiCE USE; 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;7q- .2-? / <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDate Issued 6- <br /> Triplicate) , <br /> -Triplicate)" - - r.` ` I t <br /> Application is hereby made toithe San Joaquin Local Health District° for a permit to construct <br /> and/or install the work herein described.. This .appiication :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;:e C SUS TRACT <br /> Owner's Name x ?!" • <br /> I �a��"'� U Phone <br /> Address 6/0 `City <br /> Contractor's Nem I License S Phone el1 -74c 9L <br /> l <br /> TYPE OF WORK (Check);" NEW WELL/7 DEEPEN '/7 RECONDITION' / . DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENTJ f <br /> Other /'/ j <br /> i,. <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 e <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial ; Cable Tool Dia, of Well Excavation <br /> Domestic/private 4 Drilled Dia, of Well Casing <br /> ' Domestic/public ; Driven Gauge of Casing �? <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> f Cathodic Protection 11 Rotary Type of Grout iy <br /> Disposal 1 . Other Other Information <br /> Geophysical lI Surface Seal Installed By: <br /> PUMP INSTALLATION: . Contractor <br /> Type of Pump s 3+ H.P. (o p <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: StlLa ate Work Done J A� _p <br /> pESTRUCTiON 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 Reaith District <br /> and the State of California pertaining to or regulating well construction. 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 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 GROUT G AND A FINAL 'iNS IO <br /> SIGNED TLE e;f <br /> D LAN ON REV E SIDE <br /> ARTMENT USE 0 Y <br /> PHASE I -•fir',, / <br /> APPLICATION ACCEPTED BY 1 /V DATE 'S Z `/- k <br /> TIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPE ION <br /> INSPECTION BY DATE INSPECTION BY DATE - l <br /> E H 1426 Rev. 1-74 <br /> 174 2M <br />