Laserfiche WebLink
L JOAQUIN LOCAL HEALTH DISTRICT <br /> �TF� OFFICE USE: 1 160..,-. Hazelton Ave. , Stockton, Cal_,.. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z:9 i,,/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued` <br /> (Complete In Triplicate) <br /> )plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> )d/or install the work herein described. This application is made in compliance with San Joaquin <br /> aunty Ordinance No. 1862 and the Rules a�ndfflRg lati s of the .San -Joaquin Local Health District. <br /> 7B ADDRESS/LOCATION CENSUS TRACT <br /> Nam Phone <br /> mer s Na �,3�-3 <br /> dress ,� .�': /�-�f. City <br /> sntractor'e Name , �.1License SPePhone <br /> . . i <br /> k <br /> 'PE OF WORK (Check):- NEW WELL'/;?;"'DEEPEN '/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION jt_- �PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> (STANCE TO NEAREST: SEPTIC TANK/l SEWER LINES • PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 4 <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 f V <br /> Domestic/pub_ lic 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 /> JMP INSTALLATION: Contractor r r <br /> Type of Pump �P• <br /> JMP REPLACEMENT: . . / / State Work Done i <br /> i <br /> RIP 'REPAIR / / State Work Dobe r i <br /> :S-TRUCTION OF WELL: Well Diameter Approximate Depth 1 <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> zd' the State of California pertaining to or regulating well''construction.' Within FIFTEEN DAYS: <br /> :ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> LL DRILLERS REPORT of the well and notify them before putting the.-well in.use.. . The above <br /> iformation is true to the-best of my.knowledge, and belief. I WILL CALL FOR A GROUT INSPECTION <br /> :IOR TO GROU G 'AVD A INAL N E CT WN. <br /> IGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> .: FOR DEPARTMENT USE ONLY <br /> HASE I 7 <br /> PPLICATION' ACCEPTED BY f~ DATE <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE TjVFIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 __ <br />