Laserfiche WebLink
S JOAQUIN LOCAL HEALTH DISTRICT <br /> 'OF OFFICE USE: 7 16011x. Hazelton Ave. , Stockton, Calms <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;7;7- :52, f� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _j _2a_27 <br /> (Complete In Triplicate) <br /> )plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> id/or install the work herein described. This application is made in compliance with San Joaquin <br /> )unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> )B ADDRESS/LOCATION 19528 S 9A) A-j7 yoAtLJ CENSUS TRACT <br /> mer's Name _Al m n JVQ Phone 1939" ;Zaa7 <br /> 1dress <br /> J��� 2. City L` ��.AlQ rJ <br /> )ntractor's Name �-�(/ � <br /> i d Cr✓ License �� 2LLJPhone 3Y;,)2 <br /> fPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> ISTANCE 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 \r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS G <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> IrrigatioXi_ 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 /> UMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> 'UMP REPLACEMENT• State Work Done <br /> 'UMP .REPAIR: / / State Work Done <br /> w <br /> )ES•TRUCTION OF WELL: Well Diameter Approximate Depth t <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 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 <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 GROUTING D A FIN4 INSPECTION. TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN EVER <br /> ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE. II/F� AL SPECTIO <br /> PHASE, T SPECTION INSPECTION BY ATE -, <br /> INSPECTION BY <br /> ATE P . , <br /> 1177 _ 2M <br />