Laserfiche WebLink
k V SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FOh: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 y 8-7L <br /> (Complete In Triplicate) <br /> Applicaition 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 :Wade 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 4 7 ll CENSUS TRACT <br /> Owner's Name ER A, 6,1V t Phone 3� - 7/06 <br /> Address <br /> e-, City t 3 C A,46 r' <br /> *0 J r� . . - <br /> Contractor's Name t. _ � License # c� 7901�hone <br /> TYPE OF WORK (Check): NEW WELL -L-7 DEEPEN ,/_7 RECONDITION�/? DESTRUCTION % J <br /> PUMP INSTALLATION/ / PUMP REPAIR'S PUMP REPLACEMENT Ff <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE.-DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialDia.-of-Well-Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation k Gravel Pack Depth of Grout` Seal <br /> Cathodic Pr_otect_ion Rotary Type of Grout ` <br /> 'Disposal Other Other Information <br /> Geophysical •' ' Surface Seal Installed 'B <br /> PUMP, INSTALLATION:'` Contractor <br /> * Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP 'REPAIRa <br /> . % State Work Done 6 Aj `u j2 . <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_wal_1_furnish the .San Joaquin Local Health District <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 IYOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING A JINAL INSPECTION., <br /> SIGNED TITLE c, <br /> (DRAW PLOT.;PLAN ON REVERSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I INSPECTION <br /> INSPECTION BY DATE INSPECTION BYLA— <br /> ATE f <br /> E R 1621, I_7i :. E-i�� 4%u <br />