Laserfiche WebLink
<�►� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -FOE OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466-6781 �]/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP ,PERMIT Permit No. /S1 ; <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br />, Application is hereby made to�Ithe Son 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 Regulatons'of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �C9 4 G a � 7g``�Ra CENSt#S TRACT <br /> Owner's Name din zo az _ Phone , <br /> Address - a o a City <br /> . „� License 73.5 Phone c���- 74 <br /> Contractors Name a`4 <br /> TYPE OF WORK (Check) : NEW WELL -/? DEEPEN '/? RECONDITION " DESTRUCTION /_7PUMP INSTALLATION -/-7 PUMP REPAIR -/X77 PUMP REPLACEMENT J <br /> Other `I / <br /> DISTANCE TO NEAREST: SEPTIE TANK SEWER LINES PIT PRIVY o ; <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 4 Cable Tool Dia. of Well Excavation � <br /> Domestic/private.. - I Drilled Dia, of Well Casing <br /> Domestic/public, i Driven Gauge of Casing <br /> Irrigation i Gravel Pack. Depth of Grout Seal <br /> Cathodic Protection 1 Rotary. Type of Grout ' <br /> Disposal I Other , Other Information. <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump f H.P. ! <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP ,REPAIR: /}K/ State Work Done 4ngM <br /> DES4RUCTION 'OF WELL: 'Well Diameter Approximate Depth <br /> F Describe. Material and Procedure <br /> f I hereby agree'res to comply with all laws and regulations of the San Joaquin Local Health District 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-knowled a and belief. �1 WILL CALL FOR-A GROUT 'INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSP IO . <br /> ' 'SIGNED p 01-TITLE <br /> tW PLOT PLAN ON IWVERSE SIDE <br /> ` FO r..DEFARTMENT USE ONLY <br /> PHASE I f ' <br /> APPLICATION ACCEPTED BY ^ DATE <br /> ADDITIONAL COMMENTS PHASE III FINAL INSPECTION <br /> PHASE II NS ECTION - <br /> 'INSPECTION BY DATE INSPECTION BY DATE 9= - <br /> v <br /> . w 2M <br /> D tS IA94 _ De.. '1-74 <br />