Laserfiche WebLink
-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOBiOFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> I Telephone: (209) AW:6 6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1- YEAR FROM DATE ISSUED Date Issued,', 7-,7,S— <br /> (Complete <br /> -7.S(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 che :San- Joaquin Local Health •District. <br /> t <br /> JOB ADDRESS/LOCATION Cal L-IovEa <:...."CENSUS TRACT . ' <br /> Owner's NamA A ;l ze ' P .�f Phone <br /> Address <br /> S&a, - --- - �_.. City <br /> Contractor's Name „� License IQ72010 Phone x..,2.2®7 <br /> TYPE OF WORK (Check):-"NEW-WELL /? DEEPEN -7 RECONDITION /7 DESTRUCTION f7 # <br /> PUMP INSTALLATION / / PUMP REPAIR / ,/ PUMP REPLACEMENT;, <br /> i <br /> Other' /—7 <br /> DISTANCE TO NEAREST: ..SEPTIC TANK _ SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD `r- _CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' 'PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL `'�. _ CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public .-"-Driven.- _ Gauge_of_Casing_._—'. <br /> Irrigation �. Gravel Pack f,, -- Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal - A .Other-'-. Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor - yy� <br /> Type, of Pump f _..� <br /> H.P. <br /> PUMP REPLACEMENT: ° State` Work Done iz <br /> x . . <br /> PUMP !REPAIR <br /> / 7-7-State Woik-Done <br /> M&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 Sail 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO ING AND& FINAL INSPECTION. <br /> SIGNED TITLE <br /> .. (DRAW PLOT PLAN ON REVERSE SID`W?4'�� <br /> ' } FOR DEPARTMENT USE ONLY <br /> PHASE I ! <br /> APPLICATION ACCEPTED BY DATE �' <.� <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE IIJFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY J. DATE <br /> i E H 1426 Rev. 1-74 1-74 2M <br />