Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT - - <br /> FOF�rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: e (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S S/SS/S j° <br /> THIS PERMIT EXPIRES l 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 Joaquit <br /> County Ordinance No. 1862 and the Rules and Re ulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION +. Jk24PCENSUS TRACT <br /> Owner's Name Phone 3 3c/ - a 0 c <br /> Addressn - City <br /> Contractor's Name License #/(623 7 JPhone 3 <br /> TYPE OF`WORK (Check):—NEW'�WEL - f _ = - <br /> - ION L"%��DEEPEN Jam' - RECONDIT �DESTRUCTION �f <br /> PUMP INSTALLATION /-7PUMP REPAIR '4 .PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> -INTENDED USE TYPE OF WELL k CONSTRUCTION SPECIFICATIONS <br /> ---'-~lndustrial 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 /> j Cathodic Protection Rotary f Type of Grout <br /> f Disposal Other Other Informatioti., <br /> 1 Geophysicalr,� �;� �' Surface Seal` Installed„By„:._.— ---- �<, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j / State Work Done <br /> &�State Work Done _ .-C - <br /> ES;TRUCTION 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 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 GROUT AkO A FINLJX INSPECTIO <br /> SIGNEDTITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: z— 7 <br /> PHASE IfgfXWfNSPtft PHASE III FINAL INSPECTION <br /> f INSPECTION BY DATE INSPECTION BY DATE <br /> 5 .~ <br /> ,4 E H 1426 Rev. 1-74 1-74 2M <br />