Laserfiche WebLink
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_.71�71�40/ <br /> TRIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made toithe Sari 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 and1the Rules and Regulations of the San oaquin Local,Health District. <br /> JOB ADDRESS/LOCATIONJ <br /> G CENSUS TRACT <br /> Owner's Name 'RR / Phone <br /> Address �lzw /! !74k - City O <br /> W ✓ <br /> Contractor's Name 1 d?a �/ License Phone �Z <br /> k�l <br /> TYPE OF WORK` (Check) : NEW WELL M7 DEEPEN '/—/ RECONDITION /-7 DESTRUCTION /7 <br /> f� PUMP INSTAL ATION / /; PUMP,.REPAIR / / PUMP REPLACEMENT /7 <br /> { x- r--:. �i O.ther�/�`./-r ...�t .... «..._ . __. ..- ....� --.♦ - �...,....�-.r ._ .,. .' - �,.��.._ :��,..-_ - ...,....�._ <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 WELT, O <br /> -INTENDED.;USE TYPE OF WELL t' CONSTRUCTION SPECIFICATIONS <br /> Industrial s Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public _ ' Driven Gauge of Casing <br /> Irri anon <br /> €. . Gravel Pack Depth of Grout Seal �! s <br /> Cathodic Prptection Rotary_,,.,--. Type of Grout <br /> Disposralt Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ! H.P'. <br /> PUMP REPLACEMENT: / / , State-Work Done <br /> PUMP .REPAIR: f / z"State Work D --- . <br /> DESTRUCTION OFWELL:;:; Well' Aiameter : Approximate Depth <br /> Describe Material and Procedure <br /> I hereby "agree to comply wimth--a1-1-laws and regulations of the San.Joaquin Local Health District <br /> and the State of California pertaining to or regulating well -'const-r.uction. Within FIFTEEN DAYS <br /> after completion of my work on a new:well',­I will fu-nish the-tan Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and 'notify them before;ptitting 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 INSPECTI <br /> AN <br /> SIGNED f <br /> TITLE + <br /> r. ,. M RAW, PLOT PLAN ON REVERSE SIDE) - <br /> ' . y FOR DEPARTMENT USE ONLY <br /> PHASE I jtM <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 1' <br /> Aj!ASE II GAOUT IXSPLfCTIW PHASE III/FINAL .INSPECTION <br /> INSPECTION B ATE INSPECTION BY DATE A 4 <br /> 2M <br /> E H 1426 Rev. 1-7�"°`'' <br />