Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE.OF ICE USE: 1607. E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466--6781 li <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `fid <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pate Issued 71 <br /> (Complete In Triplicate) r, <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/LOC N `f CENSUS TRACT <br /> Owner's NameF go�_ ' <br /> Phone <br /> 61 70-rir�rfoffd <br /> Contractor. ' A J�' /diV �iy ,}Address License No. OOW b*9/ phone ;?3 <br /> Contractor's NameLicense # A/ -?/�3Phone 91 <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN-J-7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION UMP REPAIR REPLACEMENT /7 <br /> Other /_7 „. <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 4 ( l <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT ONS +� <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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed _BY: r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.F. . <br /> PUMP REPLACEMENT: . / / State Work Da <br /> PUMP .REPAIR: / / State Work <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 Bistrict . <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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND FINAL INSPECTION, <br /> SIGNED TITLE ,,,z <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOP.,PEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE X-3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA III/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 12 ^7�4cf <br /> E H 1426 Rev. 1-74 1177 20, <br />