Laserfiche WebLink
�O SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �OflrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7,4_ 3 e`X <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g./44 _ �� <br /> (Complete In Triplicate) �?-`r`7_lav ZI <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 /> 12_o Pte, f' <br /> ,TOB ADDRESS/LOCATION ' P104 zk k 032 -D ,Tip.` s CENSU4 TRACT <br /> 0�a p/ <br /> Owner's Name n Phone (4a <br /> Address `�(rz_ . „ 0, 26f_ _..._- City <br /> Contractor's Name w, Sw/IoN o1 ►,� License ip Phone <br /> _ <br /> TYPE OF WORK (Check) : NEW WELL -/-T DEEPEN -/7 RECONDITION /`7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR V .PUMP REPLACEMENT /-7 rJ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> e5EWAGE-DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY- LINE - PRIVATE DOMESTIC WgWPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 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 _zzz, Other Information <br /> Geophysical Surface Seal Installed By: _. .... <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: A/7 State Work Done <br /> PUMP REPAIR; .State=Work -Done <br /> - <br /> PE&TRUCTION OF ,WELL: Well Diameter Approximate 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 WILL CALL F R'A 'GROUT INSPECTION <br /> PRIOR TO GRO TING AN2, A4FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B DATE �'-/�` 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE_I /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY .-_- DATE ge--:2 z <br /> 1 <br /> E H 1426 Rev. 1-74 1-74 2M <br />