Laserfiche WebLink
f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t <br /> FOR?'OFFICE USE: 0 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (201) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ]5=.s�pltJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued�o2-3el-ZS - <br /> (Complete In Triplicate) <br /> { epi cation is hereby made to the San Joaquin Local PIealth District for a permit to construct <br /> --` d/or install the work herein described. This application is made in compliance with San Joaquin <br /> unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 7�/ 7�7.� /67 L /�./?,/T/,/ CENSUS TRACT <br /> Owner's Name p Phone <br /> Address CityAl <br /> J <br /> Contractor's Name a icense,1461f Phon " <br /> r TYPE OF WORK (Check) : NEW WELL '/`DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT J <br /> Other <br /> INSTANCE TO NEAREST: SEPTIC TANK 2-L- 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 /> Industrial - k!= Cable Tool Dia. of Well Excavation <br /> i Domestic/private s Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing {„ <br /> Irrigation Gravel Pack Depth of Grout Seal � jrr l <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information T <br /> Geophysical Surface Seal Installed B • ^ .r <br /> I <br /> PUMP, INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REP_AIR: /7 State Work Done <br /> ' 2ES.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 /> F after completion of my work on a neva well, j 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- j <br /> information is,,true to the-best of my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> f PRIOR TO GE2gI)jQ AND A FINAL INSPCT WN <br /> SIGNED TITLE _ <br /> ! i (DRAW PLOT PLAN ON REVERSE SIDE Y <br /> FOR DEPARTMENT USE ONLY <br /> -=PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 1 _ <br /> GR T INSPECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION -DATE INSPECTION BY DATE i 6 <br /> E H 1426 Rev. 1-74 � � fJ� 1-74 2M <br />