Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br />t FOP OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITPermit No.&_43 <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquin <br />County Ordinance No. 1862 and the Rules and Regulations of the San. Joaquin Local Health District. <br />JOB ADDRESS/LOCATION W'/. _-,ya . C a' <br />r"� CENSUS TRACT . <br />Owner's Name t <br />Address <br />Contractor's Name �J_)_ZR <br />TYPE OF WORK (Check): <br />lu c rJ=5T: <br />one • % �( <br />CityE <br />License?3 Phone ]���'. <br />NEW WELL /—% 'DEEPEN��/ / RECONDITION % /.`DESTRUCTION /% <br />PUMP. INSTALLATION / �/ PUMP REPAIR. FT MP REPLACEMENT /% <br />Other `/ / --- <br />.ISEPTIC TANK SEWER LINES PIT PRIVY <br />EWAGE DISPOSAL FIELD C.VSS_POOL/SEEPAGE PIT <br />ROPERTY LINE - PRIVATE 7]OMF.gT'T1' _'t7VT T '. 'DT,DY T.. <br />'Industrial <br />Domestic/private'` <br />Domestic/public <br />?Irrigation <br />Cathodic Protection <br />Disposal <br />,k <br />TYPE OF WELL - <br />Cab 1e Togl <br />Drilled <br />Driven _. <br />Gravel Pack <br />Rotary <br />Other <br />PUMP INSTALLATION: (Contractor <br />Type of Pump <br />OTHER <br />c WFT.T- :. <br />Dia. of Weilr$xcavation <br />Dia. of Well -.Casing <br />-Gauge of - Ca"Sing -:.. . <br />Depth of Grout -Seal <br />Type of Grout <br />Other Information <br />Surface Seal Installed B : <br />H.P. <br />PUMP REPLACEMENT:. :'t/ / State Work Done <br />PUMP -REPAIR: .PAIR: �.. <br />I� �I /�" State Work Done <br />DESTRUCTION OF WELL: ;Well Diameter Approximate Depth <br />aDescribe Material and Procedure <br />I hereby agree to comply with all lams and=regulations of the San Joaquin Local Health Distri" <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,�j 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 tokhe best of -my. -knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />PRIOR GRO NG D A INSPECTION. <br />SIGNED TITLE1^ <br />PHASE I <br />APPLICATION ACCEPTED <br />ADDITIONAL COMI49NTS: <br />PHASE II <br />INSPECTION BY <br />E H 1426 Rev. 2-7 <br />PECTION <br />SE SI <br />FOR DEPARTMENT USE ONLY <br />PHAS <br />INSPECTION BY <br />DATE �3 <br />AL INSPECTION' <br />DATE <br />3/76 2M, <br />