Laserfiche WebLink
r <br /> �,/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH/OFFICE .ijUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> C Telephone : (209) 466-6781 <br /> t APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit' No.;7 <br /> j THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued-?..3 7 ' <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 n <br /> Owner's Name` �1 Phone <br /> j <br /> jl1 C C,�] - City i.( <br /> Address F <br /> ' Ce. �CN License �� Phone <br /> Contractor s Name fi <br /> TYPE OF WORK (Check) : NEW WELL/t / DEEPEN '/ / RECONDITION /—T DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC�TANK ' <<. SEWER= LINES `4 �-PIT PRIVY OC <br /> SEWAGE DISPOSAL-FIELD " - - --CESSPOOL/SEEPAGE 'PIT -OTHER- <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 0 CONSTRUCTION SPECIFICATIONS <br /> Industrialsr #y� � <br /> Cable-Too-1°°° '""'""`Dia.--'of""WeJ.I" EXcavafion""- .. <br /> P.omestic/private Drilled Dia. of Well Casing ' <br /> ✓Domestic/public Driven Gauge ,of .Casing- - <br /> TIrrigation Cefavel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Typeof Grout . h1 <br /> Disposal ' Other Other Information <br /> Geophysical Surf ace Seal Installed By: <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump ,_.""'""""` <br /> tPUMP REPLACEMENT: % -`' /A/ ~ State Work Done <br /> h A--. <br /> PUMP .REPAIR: / State Work`,Done <br /> IDESiRUCTION', OF WELL: Well Diameter Approximate Depth <br /> f Describe Material and Procedure <br /> EI hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> rand the Stale of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will flurnisl�-,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 FOR A GROUT INSPECTION <br /> yPRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED I TITLE _ ylJrlJ ul _ <br /> 4 (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ' V FOR DEPARTMENT USE ONLY <br /> 'PHASE I <br /> ;APPLICATION ACCEPTED BY DATE 3- 3- <br /> iiDDITIONAL 6MMENTS: <br /> II GROUT INSPECTION PHAS II /FINAL INSPECTION <br /> .INSPECTION DATE._ -.. _.� INSPECTION, By. <br /> -_ DATE <br /> B 7'�f <br /> ' �/'� / �.Groe 177 <br /> E H 1426 Rev. 1-74 <br />