Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 -6781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7;7_17'a4 ° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) r <br /> Application isherebymade 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/LOCATION � ��. E�S �\��. 'P�' L1 _ CENSUS TRACT <br /> Owner's Namem\C13 \£�I!r �� _ - ---. -- ----.- Phone <br /> f <br /> Address `a��5s� City <br /> Contractor's Name License # ' Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPV=/ RECONDITION /7/ DESTRUCTION /7 04 <br /> PUMP INSTALLATION PUMP REPAIR / ./ PUMP, REPLACEMENT / '� id .Y <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES ` PIT PRIVY <br /> SEWAGE DISPOSAL FIELD i�� CESSPOOL/SEEPAGE PIT . OTHERS" <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC__DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL t CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia: of Well Excavation.- -_-_ - <br /> Domestic/private <br /> 61 Drilled Dia' ,of Well Casing �t <br /> , <br /> Domestic/public ;I Driven Gauge of Casing <br /> Irrigation II Gravel Pack Depth of Grout Seal <br /> Cathodic Protection !1 Rotary Type of Grout <br /> Disposal !I Other OtheTr Information <br /> Geophysical ( Su'rface`Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / State Work Bone Lt <br /> tA, 0 w Dlv- 6-3 eZ"S "L1 /V <br /> PUMP .REPAIR:- / / State Work Dbne <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree .to comply withlall 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 E <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL KILLERS REPORT of the we_l d notify them before putting the .well in use. The above <br /> inform an is true to the f. m .knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AND A ECT <br /> SIGNE t TITLEy p�l.c <br /> RAW. PZ PLAN ON REVERSE SIDE) <br /> I <br /> FOR DEPARTMENTIUSE ONLY - <br /> PHASE t <br /> APPLICATTON ACCEPTED BY ,�. E DATE _1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO110 . PRSY FIN INSPECTION _ <br /> INSP.ECT.ION_BY^.__.-_ DATE._--- _ .___"4_.11 "INSPECTION_BY __- TE '7.--•/.S _-Z <br /> - - <br /> E H 1426 Rev. 1-74 376 2M '� <br />