Laserfiche WebLink
le J SAN JOAQUIN LOCALfHEALTH DISTRICT <br /> FOF��OFFIC USE:-~' � 1601 E. Hazelton Ave. Stockton <br /> ¢ Calif. <br /> .. Telephone: (209) 4664781 <br /> _ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> V_ ./0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 2-o ? p"-os <br /> Application is-.hereby made tot Che San Joaquin, Uveal 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 andlthe Rules and Regulations of the San Joaquin Local Health District. <br /> y.Iro �3-0 s Sato, /#0#0 0 P <br /> JOB ADDRESS/LOCATION �� /,ir1, ' , � �� AbAt �y � CENSUS TRACT <br /> Owner r s Name e�� C - "& .,, Phone <br /> Address / <br /> t City <br /> �. . <br /> Contractor's Name License # / � 1hone ' <br /> - ...�:._� <br /> TYPE OF WORK (Check): NEW WELL '/-7 / <br /> DEEPEN. __7 RECONDITION /? DESTRUCTION 1-7PUMP INSTALLATION REPAIR /sC/ PUMP REPLACEMEN_ /7 .' <br /> Other k/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER ]LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cali1e Tool Dia, of Well Excavation <br /> Domestic/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 <br /> Disposal _ Other Other Information, <br /> Geophysical !! Surface Seal Installed By:. <br /> PUMP INSTALLATION: t Contractor <br /> Type of,Pump ._� o ! <br /> H.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '•REPAIR: "/ State Work Dane h r <br /> ES;TRUCTION OF WELL: Well .Diameter Approximate Depth <br /> Describe Material and Procedure <br /> TA <br /> I hereby agree to comply with',-,41---1 laws and regulations of the San' .�aaquin Local- Health District <br /> and the State of California pertaining to or`regulating -weT1"construction.' 'Withia-FIFTEEN DAYS <br /> after completion of my:work ori a,,,new.well.,, .I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the welMl. and:_notify them before putting.the. well in-use.. The above <br /> information is .true to the-best o knowled belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO . TING AND A FINAL INS <br /> SIGNED ' ITLE <br /> {DRA LO 'P ON RE SE SIDE s. <br /> FOR- DEPARTMENT USE ONLY _€ <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE oL <br /> ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> IIiSPECTTON BY DATE ; . INSPECTION- BY (-DATE <br /> E H 1426. . Rev. 1-74 <br /> 1-74- 2M <br /> k <br />