Laserfiche WebLink
l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT G <br /> F08 OFFICE USE: .y�P 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Q� Telephone: (209) 466-6781 <br /> '.APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 'k`� <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 Joaqu: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> .TOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Q - � � Phone <br /> Address D r o� ,6AA:E rye /J � City <br /> Contractor's Name , /t� P �` License # JW7_� Phone ' <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN '/% RECONDITION /_� DESTRUCTION /7/� <br /> PUMP INSTALLATION '/ / PUNP R/�REPAIPUMP REPLACEMENT <br /> Other — <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 CONSTRUCTION SPECIFICATIONS <br /> Industrial p Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 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: J✓/ State Work Done <br /> ]"St te' &rIE'Done"'c - <br /> )ESTRUCTION 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 <br /> Health-District <br /> and the State of California pertaining to or regulating 'well ''construction. Within FIFTEE 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 /> 'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED w. r TITLE <br /> jil <br /> (DRAW:PLOT M1�m PLAN ON FF ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ?RASE I ' /J <br /> TPLICATION ACCEPTED BY i!<T�v� , t,,Lt' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 } Rev. 1-74" � 3/ 2M 'y <br /> I <br />