Laserfiche WebLink
el <br /> CO'x ,VotSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfs:O FIDE USE: 1601 E. Hazelton Ave. Stockton,c n, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 4"-,1S` <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 Joaquir <br /> ,County Ordinance No, 1862 and the, Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �.,/•� , � ,rr CENSUS TRACT <br /> 'Owner's Name .X /0� ✓'t.:01 Phone <br /> Address 1 City �'7� j�►�-�, <br /> Contractor's Name <br /> License �_ja_Z_kL'fhone VC ti?X 76 <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN %_7RECONDITION DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR REPLACEMENT /7 <br /> Other /_7_ <br /> i <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 /> x Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> f Domeatic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal d <br /> "Cathodic Protection Rotary Type of Grout - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> . ,PUMP INSTALLATION: Contractor <br /> Type of Pump .42 H.P. ✓ <br /> "PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / State Work Done �e,,e- <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 puttingthe..well in use... The above <br /> information is true to the best of my pw e'dbelief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G ING AND A FIN E I <br /> i SIGNED _ ,; TITLE 1° <br /> RAW T PLAN ON UVERSE SIDE <br /> _ FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ►.APPLICATION ACCEPTED BYDATE <br /> � <br /> ADDITIONAL COMMENTS: <br /> PHASE If GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7_S <br /> A. <br /> E E H 1426 Rev. 1-74 / h/75 2M <br />