Laserfiche WebLink
J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE PFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1/0157 to ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued $z _�, <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. 186�2and the Rules and Regulations of the S n Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION k CENSUS TRACT <br /> Owner's Name Phone D 7T_'2 <br /> Address JJ� � <br /> City Q� <br /> Contractor's Name ' License #A&0f Phone <br /> GZg <br /> i <br /> TYPE OF Y4K (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> AF <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 -r YPE OF WELL CONSTRUCTION SPECIFICATIONS \: <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic <br /> /private Drilled Dia, of Well Casing <br /> Domestic/public DriTe Gauge of Casing <br /> Irrigation rav 1 Pack Depth of Grout Seal �I <br /> Cathodic Protection -Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface ,Seal Installed B : .�. <br /> t <br /> PUMP INSTALLATION: Contractor �4�d <br /> 5-al et� <br /> Type of Pump H. <br /> PUMP REPLACEMENT: / / State Work Done O-V_0 ` <br /> PUMP �REPAIR: / / 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 /> 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 LL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING FIN L IN PE ON. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I s� <br /> APPLICATION ACCEPTED BY /-7DATE � <br /> ADDITIONAL �COMMENTS; <br /> PHASE, II GROUT INSPECTION PHqE;OTII/FIW INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 979--79 : <br /> E H 1426 Rev. 1-74 1177 - 2M <br />