Laserfiche WebLink
r: <br /> ;. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r FOF: OFFICE USE: s 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 -7 <br /> (Complete In Triplicate) <br /> F 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 /> h JOB ADDRESS/LOCATION - 1 CENSUS TRACT <br /> x, Phone <br /> Owner's Name • T't 18 <br /> d <br /> Address ^� 5 0 City 11G/ 4J✓ <br /> Contractor's Name �e�/Z� �� <br /> WC) License # LOQ - Phone -63 V <br /> TYPE OF WORK (Check) : NEW WELL '/ J DEEPEN/ J RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / J PUMP REPAIR ./ J PUMP REPLACEMENT l- <br /> L <br /> ' DISTANCE TO NEAREST: SEPTI C4TANK- 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 <br /> �. Industrial Cable .Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia.of Well_Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotary Type of Grout ' ! �V701V TE <br /> ` Disposal Other x� Other. Information` <br /> Geophysical F Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / /w'State Work Done <br /> PUMP .REPAIR: / J State Work Done <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 /> land the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> after completion of my work on a new we11, I will furnish the San Joaquin Local Health District <br /> WELL DR LERS REPORT of t well and- notify them before putting the..well in use.. The above <br /> informa i is true to th nest gf._.my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO d ING A NAL INSPECTION. <br /> S iGNED--- � • <br /> (DRAW PLOT PLAN ON REVERSE SIDE -- l <br /> FOR DEPARTMENT: USE ONLY _ <br /> PHASE I .x DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: e / a RASE III/FIN PINSPECTION <br /> PHASE II GROUT INSPECT N DATE S <br /> INSPECTION BY � �TE INSPECTIONw Y <br /> 1177C4 214 <br /> E H 1426 Rev. 1-74 <br />