Laserfiche WebLink
` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.OFFICE• USE: 1601 E. Hazelton .Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.2_SZO )o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate)' . <br /> Application is�+hereby made to the San Joaquin Local Health District for a permit to construct <br /> II` 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 v CENSUS TRACT <br /> Owner's Name J M19 D 4o4 0 _ Phone <br /> j <br /> Address City . C. /.�� <br /> r License # honey � <br /> Contractor s Name _ _ ,•Y�— <br /> j TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION_/ / DESTRUCTION /� <br /> PUMP,INSTA LATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE_ TO NEAREST,: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPER_TY_LINE.,_:-- PRIVATE_DOMES.TIC..WELD PUBLl, - L7QMES_T_IC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 1, ., <br /> . 1. �; L Drilled Dia.. of ...Well ,Casing <br /> t <br /> D6mestc/,privatey -� <br /> Domestic/public Driven Gauge of Casing <br /> ,, , <br /> Irrigation Gravel Pack Depth of~Gforrt-Seal <br /> Cathodic •P' otection� Rotary Type of Grout <br /> Disposal ` Other Other``Information <br /> Geophysical' i" ", " Surface Seal Installed By- <br /> PUMP <br /> :PUMP INSTALLATION: Contractor r •f " <br /> Type-,of Pump H.P. <br /> PUMP -REPLACEMENT: State. Work Done <br /> PUMP.REPAIR: / / State Work Done <br /> E t <br /> DES-TRUCTION OF WELL: Well-. Diameter s 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 ofzCalifornia+ pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> I after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 1 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 G OUT INSPECTION <br /> PRIOR TO GROU AND L±Ir IN5EECTION. <br /> SIGNED TITLE —*77 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS:. <br /> PHASE II UT IN ECTION PHA II INLL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY W DATE <br /> 1/77. _ 2M <br /> j P 14 lL1lA Pmir. 1-71L .._ . <br />