Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 1 <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.��3,f_3 <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 fora permit to construct <br /> and/or install the work herein described. This application is, made incompliance with San Joaquin ! <br /> County Ordinance No. 1862 and the .Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 913 CENSUS 'TRACT : <br /> Owner's Name (� ` � r % <br /> 1��✓Iv # Phone7� <br /> Address ,� ! (, <br /> _ city <br /> Contractor's Name L.lT (_, e (-L icense #Xabhone4, <br /> TYPE OF WORK (Cheek) : NEW WELL/U'—'DEEPEN/_/ RECONDITION / /v DESTRUCTION 1-7 1 <br /> PUMP INSTALLATION / / PUMP REPAIR% { / PUMP REPLACEMENT <br /> Other / / - 1. R , — i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE PIT PRIVY <br /> i SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE, TYPE OF WELL CONSTRUCTION S' P­E­­CIFICATIONS <br /> Industrial /f <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private C <br /> Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ravel Pack Depth of Grout Sea <br /> Cathodic Protection. �0.tary Type of Grout <br /> Disposal Other'- -,- Other Information <br /> Geophysical `y Surface Seal Installed By: <br /> PUMP INSTALLATION: Conira'ctor <br /> Type of Pump H.P. k <br /> PUMP REPLACEMENT:j <br /> State•-Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well 'Diameter _ Approximate- Depth <br /> Describe Material and Procedure" 7 <br /> I hereby agree to comply with all laws and regulation f the San 6eaquin Local Health District <br /> and the State of California perta n-ing _to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a newvvell., I will furnish the San Joaquin Local Health District a # <br /> WELL DRILLERS REPORT of the well and notify them before putting the welkin use... The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION, <br /> SIGNED = <br /> - -(DRAW-'PLOT- PLAN ON REVERSE SIDE) <br /> FOR.rDEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION`KCCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P S4,Xi AROUT INSPECTIOV <br /> 7 P E JWFX4AL INSPECTION <br /> INSPECTION BY,, DATEINSPECTION DATE <br /> F <br /> E H 1426 Rev_ m 1-74 2M_ 2M "4� <br />