Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk -OFFIC3 USE: 160.1 E. Hazelton Ave. , Stockton, 'Calif., r <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued r� <br /> (((0O0;,A) OV E5 7-CA) (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-,3oaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION p e �0 4s i�"7i'cS TRACT <br /> Owner's Name L Phone 4"71-68z-3__ _ <br /> Address . 1-ouLelL J e A n4Tx1 City <br /> Contractor's Name �, i License #�� Phone <br /> TYPE OF WORK (Chedk) : NEW WELL /2?;- 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 PIAT OTHER p <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELL Q <br /> INTENDED USE TYPE OF WELL - I a CONSTRUCTION SPECIFICATIONS O <br /> Industrial L---Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing y f _ <br /> Domestic/public r Driven. Gauge of Casing <br /> Irrigation I Grave V., Pack Depth_of Grout Seal � <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 3 Other Other Information h <br /> Geophysical. � ; M Surface Seal Installed B ° t <br /> PUMP INSTALLATION: Contractor ` <br /> . " Type of Pump ___ H.P. <br /> :, gE <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: s / / 'State Work Done _ <br /> DES•TRUCTI0d OF WELL: Well Diameter 1 Approximate Depth- <br /> Describe Material. and` Procedure <br /> Y � <br /> I hereby .agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Californ'ia .pertaining to or. regulating well ':construction. Within FIFTEEN DAYS <br /> after completion of my work Lon a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS}REPORT of t.he4well 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 /> t PRIOR TO GROUTING AND A FININSPECTION. <br /> AI <br /> i SIGNEDr 4 TITLES +vt <br /> 4 ` (DRAW APLOT PLAN ON REVERSE SIS) f <br /> { FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> r <br /> APPLICATION ACCEPTED BY 4 DATE 9IJ17ZA _ •�" �/� _. ,..r: �•-. <br /> ADDITIONAL COMMENTS <br /> PHASE II 4OUTiINSPECTION _" 'PHASE I I/FINAL INSPECTION- _ <br /> G iNSPECTIDN BY` DATE INSPECTION BYE -� DATE -/ �� �. <br /> 2M <br /> f H 1426 RP-u_ . 1-74 __. <br />