Laserfiche WebLink
t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh.:OFF USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,5=39X;0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe 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 <br /> CENSUS TRACT <br /> Owner's Name U m Phone , k <br /> Address a c,r City' <br /> Contractor's Name - a License # '/Ar-2W_Phone - r <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN-/-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION �/ PUMP REPAIR -/? PUMP REPLACEMENT f <br /> Other #f 7 <br /> t <br /> DISTANCE TO NEAREST.: SEPTIC ZANK 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 p Cable Tool Dia. of Well Excavation <br /> V- Domestic/private - Drilled. Dia. of Well Casing � 3 <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation 4 Gravel Pack Depth of Grout Seal <br /> Cathodic Pr_otect_ion I Rotary Type of Grout <br /> Disposal 't Other Other Information " <br /> Geophysical Surface Seal Installed 'By: <br /> PUMP INSTALLATION Contractor � <br /> Type of Pump H.P. 1 <br /> LOF <br /> PUMP REPLACEMENT: / / Sate Work Done <br /> PUMP / / State Work Done ,� <br /> --.. ._ ' <br /> DESTRUCTION OF WELL: Well Diameter "�: � Approximate Depth <br /> Describe Material and Procedure a <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 San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before, well. in.use.... The above <br /> information is true to the-best .of my kno g and` L FOR A 'GROUT INSPECTION <br /> PRIOR TO AND A FINAL INSP <br /> SIGNED AwlrfTLE ' <br /> (D ON REjftRSE SIDE <br /> 14WDEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY a. DATE g- •��` <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BV!-:. DATE �-6 -7 " <br /> E ' E H 1426 upv_ 1-74 h/75 2M _fir <br />