Laserfiche WebLink
SAN-JOAQUIN LOCAL HEALTH DISTRICT <br /> FOZ, OFFICE USE: 0?' 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 4,7 ZZ <br /> r- (Complete In Triplicate) <br /> Application is Aereby 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 Regulati of77�2-. <br /> the Sa aquin Local Health District. <br /> JOB ADDRESS/LOCATION /� CENSUS TRACT ' <br /> Owner's Name /� l7G /� Phone q7e f feo <br /> Address fQ f3 f�/ 1�PP city S'/'"l�G�rTG1V <br /> Contractor's Name e �,[f 4 Edo License # 44(12 Phone <br />,r <br /> i <br /> TYPE OF WORK (Check) : NEW WELL 'X DEEPEN /_% RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / <br /> f DISTANCE TO NEAREST: SEPTIC TANK 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 ! q <br /> Dia. of Well Excavation \l <br /> Domestic/private Cable Tool Drilled Dia, of Well Casing �n <br /> Domestic/public' Driven Gauge of Casing `s) <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information. <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ w <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP �REPAIR: / / State Work Done <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 bistrict <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 putting 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 INSPECTION. <br /> SIGNEDj!4 TITLE (.$7 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE d-7 7 7 <br /> ADDITIONAL COMMENTS: <br /> PHA. GROUT INSPECTION P INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /12 <br /> `71E H 1426 Rev. 1-74 _ 1127 <br />