Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO_ OFFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Nor. "bb�J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedZ�, Q_1� <br /> (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 the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �� 0 . - ` " �� 4- U � Q-' ! <br /> CENSUS TRACT cif' <br /> Owner's Name Phone 3�-/Zl5' <br /> Address Citr I <br /> Contractor's Name . % <br /> License . , �' � hone <br /> IIi <br /> TYPE OF WORK (Check) : NEW WELL, /'DEEPEN '/ / RECONDITION / / DESTRUCTION /_ F <br /> PUMP INSTALLATION /7/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK`" (,) .EWER LINES o - ZIT PRIVY ' <br /> SEWAGE DISPOSAL FIELVoj) -7_._CESSPOOL/SEEPAGE PIT E?r-c. OTHER <br /> ' PROPERTY LINE - PRIVATE DOMESTIC WELL3s'PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIO IS'r <br /> Industrial Cable Tool Dia. of Well Excavation Z_3& <br /> Domestic/private Dritled Dia. of Well Casing 'ms' s '/ CA <br /> Domestic/public Driven Gauge of Casing ! <br /> Irrigation Gravel Pack Depth of Grout S1p C� <br /> Cathodic Protection 4— otary Type of Graut <br /> Disposal Other Other Information ` <br /> Geophysical r Seal Installed B : * " , ,� -PUMP,INSTALLATION: Contractor�;v :,�,rface <br /> r Typ-e�f- H.P. C) <br /> PUMP REPLACEMENT: /�/ State Work Done <br /> PUMP -REPAIR: / / State Work Done <br /> F <br /> DESTRUCTION 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 San Joaquin Local Health District a <br /> WEL RILLERS REPORT of the well and notify them before putting the. well in use.. The above <br /> informa 'on is true to th best of my knowledge and _belief. I WILL, CALL FOR. A.-GROUT INSPECTION <br /> PRIOR...TO G UTING ANIS AN IwI <br /> NSIPEXTION. <br /> SIGNE ` ` ` ` "1 V " TITLE ' . <br /> w 1 I <br /> (DRAW PLOT PLAN ON REVERSE SIDE), ; <br /> FOR-DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ( /Z U <br /> ADDITIONAL COMMENTS: <br /> PHAS- I ­GROUV INSPECTI N _ PHASE TTI FINAL INSPECTION <br /> INSPECTION BY ATE /'G -INSPECTION BY DATE <br /> E H 1426 Rev. 1-74_ y 77 2M <br />