Laserfiche WebLink
a SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: (209) 466-6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit'`'No. <br /> 1 <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 aid the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONC2 <br /> CENSUS TRACT <br /> Owner's Name ZE i �T��r V _ Phone <br /> r Address 366( �.sod A,A% it 7031--- ,J <br /> f Contractor's Nam 1 Licen e i< one 3 ' W <br /> 4 . " <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_7 DESTRUCTION/_ 1r , _ <br /> PUMP REPLACEMENT -7 <br /> PUMP 'INSTALLATION '/ / PUMP REPAIR / / fiy <br /> Other 17 <br /> k � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> v SEWAGE DISPOSAL FIELD CESSPOOL%SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE-DOMESTIC:WELL PUBLIC DOMESTIC WELL p <br /> INTENDED USE `•TYPE OF WELL = ';"" CONSTRUCTION SPECIFICATIONS- <br /> Industrial } Cable Tool "`' Dia. of Well Excavation <br /> J F Domestic/private i Drilled Dia. of Well Casing <br /> ' Domestic/public Driven Gauge of Casing <br /> Irrigation 4 Gravel4Pack 14;:=-bep.th .of Grout Seal _ <br /> r Cathodic Protection Rotary - - -Type of Grout <br /> Disposal + -Other a, Other Information <br /> Geophysical <br /> ' .i. Surface Seal Installed By: <br /> '+� <br /> PUMP INSTALLATION: Contractor } <br /> TYPel of Pump 'A. try, �8 H.P. <br /> � � f <br /> PUMP REPLACEMENT- t , / / State Work Done EXCAV ATF- CY,j�` d f 3 LOW <br /> y �(�FDE - FILL CAS! P'f e- VF?F� • v f <br /> ezepPUMP .REPAIR: State Work Dane <br /> DESTRUCTION OF WELL: Well Diameter CK F IApproximate 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'I ILL CALL FOR A GROUT INSPECTION <br /> PRIOR T G G FI INSPECTION. (i <br /> M SIGNED TITLE _ .� <br /> i <br /> D W Ph T PLAN ON REVERSE SIDE) <br /> i FOR pEWTMENT ULE ONLYPHASE I <br /> / <br /> APPLICATION ACCEPTS _ Z �9 6 R 0 DATE -0O'Z.3 <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE III/VIIJAL INSPECTION <br /> INSPECTION BY• DATE INSPECTION BY d&e DATE <br /> 376 Q <br /> E H 1426 Rev. 1-74 <br />