Laserfiche WebLink
C� lcad-8 � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR:3FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> '`- Telephone: (209) 466-6781 <br /> ,APPLICATION FOR WELL -CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application: is hereby made to, the Sun 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 an& the Rules and Regulations of the San -Joaquin Local Health District. � <br /> JOB ADDRESS/LOCATION 1fa 1 p� �Ga. Ay-e— i. CENSUS TRACT <br /> Owner's Name -2/1 C_ Phone <br /> Address - / _. . City 0�6Glz <br /> Contractor's Name U" e,a` License # /j37� P. 6 <br /> 71 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/? RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION ZZT PUMP REPAIR -/—/ PUMP REPLACEMENT f7 <br /> Other / 7 jtb , <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 4 Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public i Driven v Gauge of Casing <br /> Irrigation f ` Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 4 Rotary Type of Grout <br /> Disposal F Other Other Information ' <br /> Geophysical Surface Seal Installed 'By: <br /> PUMP INSTALLATION: Contractor 0 I <br /> Type of Pump H.P. <br /> t <br /> PUMP REPLACEMENT: . / / §itate Work Done <br /> PUMP . `-State Work Done A/a­c} 4,1 rv ,� <br /> DES-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 /> f WELL.DRILLERS REPORT of the well and notify them before putting the..well. in.use.... The above <br /> information is true to the-best .ok599;; <br /> . I WILL CALL FOR-A -GROUT INSPECTION <br /> PRIOR ING AND A FINALE <br /> SIGNED a TLE <br /> SE SIDE-) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: s <br /> PHASE II GROUT INSPECTION PHASE II INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE �S <br /> E H 1426 Rev., .1-174 r 4/75 C _ <br />