Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOE OFFICE USE: (� / 1601 E. Hazelton Ave, , Stockton, Cal <br /> � �1A� �� <br /> V/ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;�g_ Lq F1a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued &o' -7G <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/LOCATI CENSUS TRACT " <br /> 01 <br />'4 Owner's Name Phone p-- <br /> Address City S <br /> Contractor's Name <br /> License #,.16 <br /> Phone <br /> i <br /> TYPE OWORK (Check) : NEW WELL117/ DEEPEN '/ I RECONDITION_/ / DESTRUCTION /� E <br /> PUMP INSTALLATION I J PUMP REPAIR / / PUMP REPLACEMENT I <br /> Other <br /> DISTANCE TONE - SEPTIC IANK „SEWER LINES T' ' 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 Cable Tool Dia:`6f Well Excavation <br /> Domestic/private Drilled bia. -6i Well Casing <br /> Domestic/public Driven Gauge�-Of -Casing <br /> Irrigations Gravel Pack Depth-of 'Grout Seal <br /> f <br /> Rotary Type of Grout <br /> Cathodic Protection <br /> --777-Disposal Other Other `Inf ormation... <br /> a .'U <br /> Geophysical. Suce rfaSeal Installed B <br /> �` � ;� �. ''"+ � ;.1 ��' . t..7'•+�` ti's �'� � •�� - <br /> PUMP INSTALLATION.i ­ Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT.:, _�, �-/"/ -State Done <br /> - k .' <br /> .r <br /> PUMP .REPAIit: / JN State Work Dorfe <br /> DESTRUCTION OF WELL:. Well Diameter "`-✓ Approximate Depth <br /> Describe Material. and Procedure <br /> I hereby agree to comply with all laws and regulations ,af'fhe�'San Joaquin Local Health District <br /> and the State a ornia pertaining to or regulating we11'construction. Within FIFTEEN DAYS <br /> after comp le on of my work on a new well will furnish .tWS San Joaquin Local Health District a <br /> WELL DRILL)&S REPORT the wel a n i€ them before;�putting the .well in use. The above <br /> informat n -is.6 a the b edge and belief I WILL CALL FOR A GROUT INSPECTION., <br /> PRIOR TO �GRO A F <br /> SIGNED---- - 1 TITLE <br /> DRAW Ptbt PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE' ONLY, <br /> PHASE I �* , <br /> ' APPLICATION ACCEPTED BY �..t _ ti ":�.DATE <br /> ADDITIONAL OOMMLNTS: -- <br /> PHASE II. GROUT INSPECTION PHASFINAL INSPECTION <br /> INSPECTION BY DATE ` INSPECTION_BY DATE14 <br /> 3/7b 2M <br /> k E H 1426 Rev,_ 1-74 <br />