Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORI'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6.781 <br /> APPLICATION FOR WELL CONSTRUCTION QR PUMP PERMIT Permit No. <br /> E� <br /> THIS PERMIT EXPIRES l YEAR- F'ROMnDATE ISSUED Date Issued <br /> u. (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Distirict for a permit to construct <br /> and/or. install the work herein described. This applicati',vn 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 ADDS)LOCATION' . I �or, 2S�SUS TRACT <br /> Owner°s Name ki'cA A2 ( " i� <br /> h o� � a Phone 3 6 ,?-..� 6 2 {,�..� <br /> Address G 5 '�' City L ,' <br /> Contractor's Name £ 4, EA P , �rx :� License SIG 23 7-3 Phone-?(. <br /> TYPE OF WORK (Checit): NEW WELL /? DEEPEN -/? RECONDITION /_7 DESTRUCTION <br /> AL /7 <br /> PUMP INSTLATION / / PUMP REPAIR! / / PUMP REPLACEMT f <br /> Other 1Y _A-1 L v C LIE &4 C L . Lr c Vu�� j <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 4 ,.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 - 4 _CONSTRUCTION SPECIFICATIONS r <br /> Industrial Cable Tool Di:av i of Well Excavation <br /> Domestic/private I Drilled Dia. A.-Well. Casing <br /> Domestic/public Driven Gaugeof Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> ` . Cathodic Protection Rotary , Type of Grout" <br /> 'Disposal Other '" `Other Information <br /> Geophysical, . ? y Surface Seal Installed By:-31 <br /> PUMP INSTALLATION: Contractor <br /> Type of 'Pump c. h H <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUM1.' '.REPAIR: /_7 State Work-Done, <br /> 1 <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> IDescii6 '-'�iater isl-and Procedure — <br /> t <br /> I <br /> I hereby agree to comply with all laws-and regulations ofthe 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 furnishll: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-beat of my ..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROWUNGOAND F AL INSPECTION. <br /> SIGNED I TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , !i _ <br /> AP—PLICATION—'ACCEPTED BY i DATE <br /> ADDITIONAL COMMENTS: ri� <br /> PHASE II GROUT INSPECTION ,._ I� PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /Y <br />�' E H 1426 Rev. 1-74 1-74 2M <br />