Laserfiche WebLink
- �/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> = FOArOFFZ E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> : + APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No."7Ld 1 c- p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 30-11-L, <br /> (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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner'°s Name �1""�,, �. ' <br /> Phone <br /> Address <br /> City r1 st�Y--old <br /> Contractor's Nam ` �, <br /> License #/�phone W>,74_74 <br /> f <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN -/7,_ RECONDITION /_7 DESTRUCTION %j <br /> PUMP .INSTALLATION 1_7 PUIMP REPAIR / PUMP REPLACEMENT <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 WELL' ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS U <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �. <br /> Domestic/public Driven Gauge of Casing I <br /> ._Y Irrigation Gravel Pack Depth of Grout Seal ` <br /> Cathodic Protection i Rotary - Type of Grout- <br /> Disposal <br /> R <br /> Disposal Other Other Information <br /> -Ge ophysical 'Surface Seal Installed By: <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump A.P. S' i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP !REPAIR: State Work Done <br /> ESIRUCTION 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 <br /> Lbcal <br /> and the State of California pertaining to or regulating well construction. WithinaFIFTEENtDAYS <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..wel1 in.use.. The above <br /> information is true to the-best-of my-knowledge and belief. I WILL"CALL FOR A'GRQUT INSPECTION <br /> PRIOR 0 TING AND A FINAL I SP CFIQN <br /> SIGNS ITLE / » <br /> (DRAW PLO PLAN ON FRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY .J DATE - "7� <br /> E H 1426 Rev: 1-74 -74 2Ht <br />