Laserfiche WebLink
C .h, • -- N 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. 74.3 71�,O <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued q' <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION i o 0 <br /> /2 -� Ta CENSUS TRACT <br /> _. Owner's Name �• �Cc cc..6/, Phone <br /> Address / 001 _' TGt! � 7®r; r +'M City <br /> Contractor's Name �.,� // cru"42 L License 11 ! 3 7 tS Phone -1Ay -T J6 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN / / RECONDITION /7 DESTRUCTION _� <br /> PUMP INSTALLATION /—/ —PUMP REPAIR /tf/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY O . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL _ �1 <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: Contracto <br /> Type of Pump V -7-ki k H.P. U <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: k7 State Work Done "j /n til �ii�., ., h r Y le <br /> pES•TRUCTION 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 CALL FOR A GROUT INSPECTION <br /> - PRIOR TO GROUTING AND A FINAL INSPECPI N. <br /> SIGNEDI=TITLE nom' _ <br /> (Dpj PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 7// <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE G_�:� <br /> E H 1426 Rev. 1-74 '"1§ 1-74 2M <br />