Laserfiche WebLink
SAN JOAQUIN LOCAs. HEALTH DISTRICT <br /> ' FORi'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR'PUMP PERMIT Permit No. p <br /> THIS PERMIT EXPIRES I YEAR FROM .DATE ISSUED . Date Issued -s-1�/_ <br /> (Complete In Triplicate) <br /> Application is hereby made to I the Satz Joaquin Local Health District' fora permit to construct <br /> and/or install the workherein described. This .application .is made in compliance with San Joaquin , <br /> County Ordinance No.-.1862,andlthe Rules and Regulations ofAfhe San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION-,,T , a C SUS TRACT <br /> ;Owner's Name - <br /> 3 <br /> Phone <br /> CN <br /> Address .. 7Q(,6 . ., �v U4)k L1 �r` <br /> .Ci,tq <br /> Cantraetora Nome License # dA7x Phone = -7e.aL <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /7 . DESTRUCTION f7 <br /> PUMP .INSTALLATION /7 PUMP REPAIR &_7 PUMP REPLACEMENT 17 <br /> ` Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER,,LINES PIT PRIVY b <br /> SEWAGE DISPOSALFIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY. LINE - PRIVATE DOMESTIC WELL � PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Well Excavation <br /> Domestic/private t 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 t Rotary Type of Grout' <br /> i Disposal i . Other Other Information ' <br /> Geophysical 'Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ,4 H.P. 4 <br /> PUMP REPLACEMENT: I . <br /> StI ate Work Done , <br /> I <br /> PUMP !REPAIR: <br /> State Work Done <br /> _&_-.jtzLe d2t-AO�V <br /> E&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 t <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 putti.ng..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 GROUTING AND A FINAL INS IO <br /> SIGNED TLE e <br /> (DBPTLOT PLAW ON REV SE SIDE <br /> PHASE I <br /> ARTMENT USE ONLY <br /> � , <br /> APPLICATION ACCEPTED BY /V DATE <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPEC ION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> VE H <br /> 1426 Rev. 1-74 1-74 2M <br />