Laserfiche WebLink
r. Cj SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO iOFFICE USE: 1601 E. Hazelton Ave. , Stockton, 'Calif. i <br /> Telephone: (209) 466-6781 t <br /> APPLICATION FOR.-WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZE_ <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 and the R les an Rei gulations of the San Joaquin Local health Dstrict. <br /> JOB ADDRESS/LeCATION ► CENSUS TRACT r <br /> Owner's Namei' ' A 4-F 2 S Phone <br /> Address _� , '� DD A— .- y ------ -- city <br /> Contractor's Name License 4 _ .- Phone <br /> PE OF WORK -(Check): NEW WELL IAZ; DEEPEN -/? RECONDITION /-" DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT 1 <br /> � Other �/ / <br /> I <br /> 'DISTANCE TO NEAREST: SEPTICMTANK - SEWER LINES PIT PRIVY <br /> SEWAGE:DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER + a <br /> + PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE. TYPE OF WELL. CONSTRUCTION SPECIFICATIONS E��11l <br /> industrial a able Tool Dia. of Well, .Excavatidn' J12 ;fit! <br /> �-Bomeatic/private : Drilled Dia, of Well Casing <br /> Domestic/public. i Driven Gauge of Casing . 6 <br /> Irrigation " Gravel Pack Depth of Grout Seal u <br /> Cathodic Protection Rotary Type of Grout. <br /> Disposal Other Other Information � I <br /> P S <br /> Geophysical Surface Seal Installed B ` <br /> PUMP INSTALLATION: Contractor <br /> Type of Fume . - H.P. ' <br /> a <br /> PUMP REPLACEMENT: /�/ State Work Done <br /> PUMP :REPAIR: -- /-7 -State-Work -Done= ---- - <br /> ES 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 DAYSf <br /> after completion of my work on a new well, I will furnish the San Joaquin. Local Health District:1a <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 FOR A GROUT INSPECTIONf <br /> PRIOR TO"G OU ING ANDA FINAL ECTION. <br /> SIGNED to�! TITLE Aja v- / <br /> (DRAW PLOT PLAN ON REVERSE SIDE") - � <br /> FOR DEPARTMENT USE ONLY �k <br /> PHASE I <br /> APPLICATION ACCEPTED•.BY �' _ _ � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE • -71"f INSPECTION BY DATE /,2- <br /> E H 1426 Rev. 1--74 1-74 2M <br />