Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOErOFFICE 15E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> .�.��- Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��9V <br /> THIS PERMIT EXPIRES l YEAR FROM BATE 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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4� / 7 CENSUS TRACT <br /> �.P` Phone ���Sd� <br /> Owner's Name <br /> Address City <br /> Can actor's Name 4-tl T - P- ' ` License # Phone <br /> TYPE OF WORK (Check): : : NEW __ N / 7 - - - <br /> NEW WELL /?,,.,.DEEPEN-:./. �RECANDTTION /_� DESTRUCTION S <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 - <br /> ' Other <br /> 7 - <br /> ' Other / / <br /> DISTANCE TO NEAREST: 'SEPTIC TANK SEWER LINES t PIT PRIVY rr <br /> _s SEWAGE DISPOSAL FIELD CESSPOOL/SEEPA_GE-PIT :' OTHER <br /> � . ,;PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC -DOMESTIC WELL <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , Cable Tool Dia. of Well Excavation U <br /> Domestic/private) Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth o.F_Grout.-Seale,--�,.— _ <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: / / State Work Done <br /> PUMP :REPAIR: L7 State Work Done - <br /> / <br /> VES�RUCTION OF WELL: Well Diameter o �tu tu ipp2oximate Depth 70 <br /> Descr Mater ala roc re , <br /> �d2r c;� evl a G'9 Glj. <br /> I hereby agree to comely h all i s and eg 1 t ons o e San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. k 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 t8' the-best-of my-knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO OJUNG AND I1'A YINAL TASZEjCTI0,U <br /> SIGNE TITLE— <br /> ip LOT PLAN ON REVERSE SIDE <br /> / FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED $Y DTE <br /> ADDITIONAL COMMENTS: I. j <br /> PHASE I0k0VT--MPfCTION FHA INSPECTION <br /> INSPECTION BY �I' INSPECTION BY DATE <br /> s E 11-1426 Rev.-11 <br /> -.074-- I-74 2M <br />