Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFICE USE: 1601 E.. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-�S74� <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 3oaquin Local Health District. <br /> JOB ADDRESS/LO CENSUS TRACT 6?&S'• 2'70--d7 <br /> 93 <br /> Owner's Name 3 ' Ph <br /> 11 r',•� f <br /> one <br /> Address -- ,t o{ <br /> Contractor's Name License #A-�Q%? Phone <br /> TYPE OF WORK (Check) : NEW WELL .L7T-_`bEEPEN /7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION C PUMP REPAIR /7J PUMP REPLACEMENT /7 <br /> Other 1 7 �. <br /> DISTANCE TO NEAREST: SEPTIC TANK 7,,✓,--' SEWER LINES PIT PRIVY � U3 <br /> SEWAGE DISPOSAL FIELD CESSPOOL,/SEEPAGE PIT OTHER W <br /> PROPERTY LINE - PRIVATE DORESTIC WELL'" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ✓D'6mestic/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 C�i�r� r,BT <br /> Disposal.,: Other Other Information <br /> Geophysical. -`� � Surface Seal Installed BY: :Dr2jj.;,. jE <br /> PUMP INSTALLATION: Contractor <br /> a.. q <br /> { :w Type-;:of Pump H.P. <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP-'.REPAIRt « _ �: State Work Done <br /> ES•TRUCTION <br /> ,A o OF -WELL; Well Diameter :- ._ Approximate Depth <br /> „r_ <br /> Describe Material and Procedure' � * <br /> S <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 puttingthe 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 AND A FINAL INSPECTION. <br /> SIGNED TITLE �j , <br /> T DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT.USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE --16P- <br /> E H 1426 Rev. 1-74 <br /> 1-74 2M <br />