Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT - `- - <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or, i.nstall 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 /> I <br /> JOB ADDRESS/LOCATION /3 /3 `7 /f/ ♦ y '� CENSUS TRACT <br /> OwnerPs Name 9-al/b02s ,,, <br /> Address city <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN <br /> /-7 RECONDITION /-7 DESTRUCTION /? <br /> PUMP INSTALLATION / PUMP REPAIR / /PUMP REPLACEMENT— <br /> Other f-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK d SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL f PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> / Domestic/private Drilled Dia. of- Well, Casing �} <br /> Domestic/public Driven Gauge of Casing - /,;7 <br /> Irrigation Gravel Pack Depth of al Grout Se — — ' <br /> Cathodic Protection Rotary Type of Grout ,� <br /> Disposal. Other <br /> ��� Qther Information AL1 <br /> Geophysical Surface Seal Installed B ; <br /> - ._ <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpZ. p a H.P. <br /> PUMP REPLACEMENT: / / State Work Done AhaD W S Dt 1 <br /> f� V DED In/ 177-T <br /> _ <br /> PUMP :REPAIR: 1)L- '7 3 311 - WFC 04477f PtV 7 .}j 6 tv 0 <br /> /? State Work Done _ � E <br /> i <br /> ES•TRUCTION OF WELL: Diameter 4 PrPPR4DV EP- O.D-L- 77A,0- <br /> 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 /> WELL DRILLERS REPORT a well and notify them before putting the-well in use.. The above <br /> information o the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOECT N.. <br /> SIGNED TITLE <br /> (DRAW P FLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTS BY DATE . <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE I FIN L INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 1-74 2M <br />