Laserfiche WebLink
64„ / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0_K7OFF10E USE: V 160 . E. Hazelton Ave. , Stockton, Calif. <br /> 4 Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL .CONSTRUCTION OR PUMP PERMIT Permit No. 26_&p � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 7( <br /> x (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 'arid 'the Rules and Regulations of the San Joaquin Local Health District. <br /> . � <br /> JOB ADDRESS/LOCATION 2 CENSUS TRACT <br /> Owner's Name. « - Phone "•' <br /> Address rYr City <br /> Contractor's Name 9W, J�- <br /> 5 License # Phone <br /> :t <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN Pr-�RE CONDITION %f DESTRUCTION f7 <br /> PUMP .INSTALLATION / / PUMP REPAIR/� PUMP REPLACEMENT /7 i <br /> Other <br /> DISTANCE TO NEAREST`-.'—SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE-PIT —btHER'— ' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL : <br /> INTENDED USE TYPE OF WELL CONSTRUCTION-SPECIFICATIONS <br /> Industrialable Tool Dia. of Well Excavation <br /> —to'mestic/private Drilled Dia. of Well Casing \\� <br /> Domestic/public Driven Gauge of Casings <br /> Irrigation 4 Gravel Pack Depth of Grout. Sealy" Y. -yr <br /> Cathodic Protection .1 Rotary Type of Grout <br /> Disposal Other Other Information t <br /> Geophysical ' _ Surface Seal Ins talled'-�B ;- �z <br /> PUMP INSTALLATION: Contractor !f /✓ \�4 <br /> Type of Pump — --.YCA-- �• ... H.P. \"^y <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP ,,REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Di-meter Approximate Depth <br /> Describe Material and Procedure _ <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distfict <br /> and the State of California pertaining to or regulating well construction. WithinlFIFTEEN'DAYS <br /> after completion of my work ona. new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the.-well 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 INSPFYCTION. <br /> SIGNED TITLE � « t <br /> ZL DRAW PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY ; <br /> PHASE I / <br />-APPLICATION ACCEPTED BY DATE J1 /71S <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION, PHASE III FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY rifJi DATE 6 <br /> 075 t <br /> E H 1426 Rev. 1--74 �"� `�� �. <br />