Laserfiche WebLink
f C'Drn �rc 4,e SAN JOAQUIN LOCAL HEALTH DISTRICT -- - <br /> FOWOF I.CE USE:= 1601 E. Hazelton Ave. , Stockton, Calif. <br /> T Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �- <br /> r <br /> THIS PERMIT EXPIRES 1 "YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local .Health District for a permit to construct <br /> f and/or install the work herein described. This application is made in compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joa uin Local Health District. <br /> r c <br /> JOB ADDRESS/LOCATION ` ,! „� AitCENSUS TRACT <br /> Owner's Name Phone <br /> Address O rte' Cit C <br /> s y _ <br /> Contractor's Name cense #414 2Ad Phone y <br /> i <br /> .. f Yt .. al f.O�'Mr•+oi.rt� - - xv N. '+bti*�oc i _. - � - r wt �T.r .r +.--rrMr._ _ <br /> TYPE OF WORK (Check): - NEW WELL / DEEPEN -/•7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /RC1 <br /> Other PUMP REPLACEMENT /7 <br /> /% T <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> i Domestic/public Driven Gauge of Casing <br /> E x Irrigation Gravel Pack Depth of Grout Seal <br /> 7 Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump tt✓ H.P. p <br /> PUMP REPLACEMENT: f/7 State Work Done <br /> r..PUMP '.REPAIR: r �.:;.;;�-/)tom -',State�Work-Donee - <br /> M-TRUCTION OF WELL: Well Diameter ��� Approximate Depth `r <br /> Describe Material and Procedure <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 f <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 wled bel f. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 92RUZING D A FINAL INSft4QTt0A1 <br /> SIGNED TLE <br /> RAW PLOT PLAN ON FRSE SIDE <br /> F EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� , DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S I /FINAL INSPECTION <br /> INSPECTION BY 6 ' DATE INSPECTION BY DATE <br /> A. -- <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />