Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> FOP OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �— y <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -77-1;v <br /> THIS: PERMIT EXPIRES 1. YEAR FROM DATE ISSUED.. .Date Issued '7, ' <br /> (Complete In Triplicate) <br /> Application is hereby made to,Ithe San Joaquin Local Health District for a permit to construct <br /> and/or i.nstall .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/LOCATION / CENSUS 'TRACT ' <br /> Owner's Name !� r Phone Z-c2 <br /> Address ;. .... _ City <br /> Contractor's Name ^, License itf ,Sione �? <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ RECON➢ITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> T <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES p PIT PRIVY N <br /> SEWAGE" DISP -AL YIELD C SSPOOL/SEEP�.GE PIT OTHER <br /> PROPERTY LINA PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL §- CONSTRUCTION SPECIFICATI <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia, of Well Casing / <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack '`Depth of Grout Seal fJ� <br /> Cathodic Protection i Rotary ,e Type of Grout <br /> "e.,*Disposal Other .Other Information <br /> Geophysical` Surface Seal Installed By : <br /> 4 � r <br /> j PUMP INSTALLATION: Contractor <br />! Type orf -Pump /y. Ll _ H.P.++ <br /> PUMP REPLACEMENT: / / State Work Done <br /> I <br /> PUMP ,.REP,AIR:" / / State Work Done <br /> k DESTRUCTION OF WELL: Well Diameter: � Approximate Dept ^' <br /> s <br /> Describel Materiald and, -P`ibce ur(--' <br /> I I hereby agree to comply with all,lawa and regulations of the San Joaquin Local Health 'Dist.rict <br /> and the State of California pertaining to or regulating well:'_construcV 1.tion. Within FIFTEEN}3lAYS <br /> after completion of my work-,on ,a new well, I will furnish th•e` San Joaquin Local Health District a <br /> he wel <br /> WELL DRILLERS REPORT of Ll and `notify tgelm before putting the we11``in use. . The above _ <br /> information is true to:?the best of my knowledge and belief. I Wltt---CALL FOR A GROUT INSPECTION <br /> PRIOR TO G NG A_F)!4L4,4 INSPEC ON. ; <br /> SIGNED : `$' r TITLEP!��---- <br /> 4 4C 7&Z (DRAW PLOT PLAN ON REVERSE Sl <br /> FOR=DEPARTMENT USE,ONLY,.,,. .; 0 � <br /> PHASE• I- .� -,. .�:.....r..•�---� ,.�-��� „� --� -._.. .,e.--- <br /> APPLICATION ACCEPTED BY - DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUV INSPECTION P EI/ NAL .INSPECTIO �y <br /> INSPECTION BY DATE INSPECTION BY DATE J -7d <br /> 2M <br /> E H 1426 Rev. <br />