Laserfiche WebLink
SAN JOAQUIN-! IIiAL HEALTH DISTRICT <br /> F06 OFFICE USE: 160: Hazelton Ave. , Stockton, Cal <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-t136/� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z, , 3_js <br /> (Complete In Triplicate) <br /> 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of, the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ZT L ( �' Z� CL% CENSUS TRACT <br /> Owner's Name % 4 u�7, l� z Phone <br /> Address T City C_ <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /t DEEPEN / / RECONDITION /_7 DESTRUCTION / <br /> PUMP INSTALLATION / / 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 - PRI_VA IX My - 7 PUBLIC DOMESTIC WELL p <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Y <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 e Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done r <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter � � Approximate Depth <br /> Describe Material and Procedure <br /> ..ce�-11 - arm=� St <br /> I hereby agree to compl� 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 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 R TING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR $EPARTMENT USE ONLY <br /> PHASE I J r (/- _ <br /> APPLICATION ACCEPTED BY � �,jS' L-L DATE -Z7 -� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I PECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _ _ ^ <br /> E H 1426 Rev. 1-74 4/75 2M <br />