Laserfiche WebLink
!� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOPiOFFPCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I 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 L-22_2,�' <br /> I (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 and the Rules <br /> /and <br /> Regulations of Vt San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 7 4 <br /> CENSUS TRACT <br /> Owner's Name Phone4 <br /> Address ,7 _1 r Cityj�-ea <br /> .� tt <br /> Contractor's Name P�1-l_fp ��� ~=� License ffPhozW e'W <br /> TYPE OF WORK (Check): NEW WELL JV--_�DE EPEN /? RECONDITION /7 DESTRUCTION /7Y ` <br /> PUMP INSTALLATION / I PUMP REPAIR / / PUMP REPLACEMENT f7 <br /> Other / ./ v <br /> 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 SPECIFICATIO S <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> j g/Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing .� <br /> Irrigation ! Gravel Pack Depth of Grout Seal --5-0 <br /> Cathodic Protection17-Rotary Type of Grout .....,..,..__...___ <br /> Disposal � j Other Other Information C <br /> Geophysical Surface Sea4 Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP:!REPAIR:� tate. Wo k/�":_..:5 r =Done <br /> ES.-TRUCTION OF WELL: Well Diameter ; Approximate Depth <br /> Describe Material and Procedure <br /> I <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 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> t SIGNED . f, TITLE <br /> lIf .�' 3'' .z DRAW PLOT PLAN ON REVERSE SIDE <br /> � kk <br /> PHASE I FORnDEPARTMENT USE ONLY <br /> zz:t ,�, >t A <br /> APPLICATION ACCEPTED BY ., DATE l 7 <br /> ADDITIONAL COMMENTS: <br /> PHAS II GROUT.INSPECTION `r.C, PHASE 1� I FINAL INSPECTION <br /> INSPECTION BY '`DATE" 1q INSPECTION BYyl DATE <br /> � � E H 1426 Rev. 1-74 1-74 2M. <br />