Laserfiche WebLink
SAN JQAQUI1* LOCAL HEALTH DISTRICT ,b <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. * Y <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6_j <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Focal 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 1 'O 3 ,2_ z�7 ,7 CENSUS TRACT <br /> Owner's Name' �' ` �r� Phone KV Z,,4-" 6 r <br /> Address M)21� ��°7 -Ar cityzh,i /I- /�t <br /> Contractor's Name �/_ !/s pl�J License lj,�,��',,ZG --Phone %�� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR IN PUMP 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 \ <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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 4 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <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 thewell 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 G TING A FIN -IN PECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II G PE ION PHAS III/F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE <br /> E H 1426 Rev. 1-74 <br /> 1/77 . . <br />