Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.OFFIC USE: 601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z 7-,�y� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby madeto 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 Joaquii <br /> County Ordinance No. 1862 af,d the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4, <k 0 <br /> 4 CENSUS TRACT <br /> Owner's Name Phone <br /> Address 7 7 S /if, y' City "�, �4 _— <br /> f <br /> Contractor's Name Ll License # I¢3 ayl--Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN %/ ~RECONDITION f-1 DESTRUCTION /7 <br /> i PUMP. INSTALLATION REPAIR/ / PUMP REPLACEMENT /!77 <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 USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing L <br /> �( Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout6� <br /> Disposal. Other Other Information <br /> Geophysical Surface Seal' Installed BY: <br /> PUMP INSTALLATION: Contractors �. <br /> Type"of Pump <br /> q l�rG <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .BAR: /)'/ State Work Donesrtld,r �� G <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 6f the San Joaquin Local Health District <br /> and the State of California pertaining to or-regulating well 'eonstruction. Within FIFTEEN DAYS <br /> after completion' of my work on a new yell, I `will furnish the San Joaquin Local Health District <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 T TING AND A FINAL PEC IQ <br /> 'SIGNED �3 k .!'` ..�- TITLEr�l' <br /> (DRA PLOT PLAN ON �ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IIROUT INSPECTION P_ SE II/_ FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> i <br /> 1. 1Z.7 - 2ME H 1426 Rev. .1--74 <br />