Laserfiche WebLink
�P 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 Issued6 <br /> t (Complete In Triplicate) <br /> Application is hereby made tolthe 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/LOCATIONi/ i�, <br /> Z. a S�' cENsus TRACT <br /> Owner'a Name h Phone ` <br /> Address �1 U _ city - ,��oc.GiJ <br /> Contractor':6 Name License #&.23 <br /> _VP hone — S� <br /> TYPEeOF WORK (Check) : NEW WELL/_7 DEEPEN '/-7 T <br /> RECONDITION /_7 DESTRUCTION f <br /> PUMP INSTALLATION 'L/ (PUMP REPAIR-2-PUMP REPLA E T /7 <br /> Other /% JZA <br /> DISTANCE-TO NEAREST: SEPTIC TANK v f.SMJPR LINES PIT PRIVY <br /> 3^ 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 Cable Tool Di-a',, of Well Excavation <br /> Domestic/private Drilled Iiia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation Gravel,Pack x Depth of Grout Seal <br /> Cathodic ProtectionRotar) Type of Grout <br /> Disposal ,..Other ,X\ Other Information <br /> Geophysical ' - face Seal Installed By: <br /> .y <br /> PUMP INSiALLATIONo Contractor. S <br /> Type of.,�P.cuap --��� 1 j H.P. <br /> UMP REPLACEMENT: State Work Done <br /> PUMP '.REPAYRE/ State Work Done <br /> DESTRUCTION {OF WELL'-. Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> XA <br /> I hereby agree to comply with all laws and' regul.afions _of,the San Joaquin Local Health District <br /> and the�S ate o fornia pertaining-{to or regulating'well `-construction. Within FIFTEEN DAYS <br /> afterAgomple on of-i - work onTa .n'ew well, I will furnish the San Joaquin Local. Health District a <br /> WEi; DRILL S-REPORT f the we notify them before putting the- well in-use.. , The abov40 <br /> fnformat n Is true o t b f y. knowledge and belief. I. WILL CAlrh XOa A GROUT INSPECTION <br /> PRIOR TO GR01 I G A ECTio <br /> SIGNED ' "� F. TITLE <br /> (DRAW..PLOT PLAN ON REVERSE SIDE <br /> _`FOR APARTMENVUSE ONLY I. <br /> PRASE I I - ""_. 1„ � <br /> _L :: i !: <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDT;IONAL COMMENTS: SC <br /> ��-PHASH­11 9ZOUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 7 DATE INSPECTION�BY DATE <br /> E H 1426 Rev. 1-74 /ac >M <br />