Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7f.-1440 9 ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedo <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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION L 4J/e - CENSUS TRACT <br /> Owner's Name Joh e �Cz'/ �� Phone3/� I <br /> - r <br /> Address cityJ - <br /> Contractor's Name License # Phone L i <br /> TYPE OF WORK (Check) : NEW WELL 1;q DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION '/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE-OF WELL; CONSTRUCTION-SPECIFICATIONS <br /> Industrial Cable 'Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing _- 4 <br /> Domestic/public Driven Gauge of Casing _-__- <br /> Irrigation Gravel Pack Depth of Grout ,Seal <br /> Cathodic Protection Rotary "',,Type of Grout r <br /> Disposal Other Other Information <br /> Geophysical Surface- Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump u H.P. <br /> PUMP REPLACEMENT: . / / State Work`Done A_ <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter f„ fr --- Approximate Depth 41 ,� <br /> I <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 riew-well- I -will~furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPOf the -Vell -and.-notify.:them before putting the well in use. - The above <br /> information i tr RT to the 's-t° d my..Fknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T FIN ECT N. r <br /> SIGNED TITLE <br /> D PLOT PLAN 'ON RE VERSE SIDE) <br /> F R DEP TMENT"USE ONLY­ <br /> PHASE <br /> ' <br /> PHASE I � � <br /> APPLICATION ACCEPTED BY DATE y/7 e- <br /> ADDITIONAL COMMENTS: <br /> PHASF, JX GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> 113.SPECTION BY DATE O-_41-7,8 INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1--74 <br />