Laserfiche WebLink
1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: "'" 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z?- zp s <br /> THIS PERMIT EXPIRES I 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 /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION YLg2 . I iUe- NSUS TRACT <br /> I <br /> Owner's Name ' <br /> h1 Phone 9Le- ;;y/91 <br /> Address v',Q - g <br /> City A C AjoRJ l <br /> Contractor's Name sli. License f (J/z) Phone <br /> .7 <br /> j <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN /_/ RECONDITION /-7 DESTRUCTION /7 ' <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER n ' <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL V j <br /> INTENDED -USE TYPE OF WELL * \CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation �l ! <br /> Domestic/private Drilled # rw ' Dia.p,ofWell Casing <br /> Domestic/publicDriven badge of Casing N <br /> Iriiga-vior►- 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 INSTALLAT11ON: Contractor <br /> Type of Pump -t H.P. <br /> PUMP REPLACEMENT: State. Work Done r ' <br /> a <br /> , - k,ILe/101 <br /> PUMP -REPAIR,:.. ,, �,r,:.,� h .:/a/ State.�Work Done• <br /> DES.TRLICTION'OF WELL c `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 .isstrue to the best -of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION i <br /> PRIOR TO GROF ING ANDA NA INSPECTION. i f <br /> SIGNED _ # - _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY 4 <br /> 1 <br /> PHASE I <br /> APPLICATION ACCEPTED BY .4 C. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION PHASE I I/ AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYt . • DATE " <br /> F u IL9h Via., � 1_7A A IZ7: 1:2M <br />