Laserfiche WebLink
Permit No. <br />1)ate Issued <br />Approximate Depth <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />FOE OfFICE USE: 1601 E. hazelton Ave., Stockton, Calif. <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Joaqo <br />1.ounty Ordinance No. /1862 and the Rules and Regulations of the San Joaquin Local Health District <br />1•iaii, - / 6-.0 1.0 as: 1r S7 'Oc. o F rM ,e4.721 -1 <br />50k-rt-/ e' Dev,edes Aeotqzto CENSUS TRACT JOB ADDRESS/LOCATION /Ur:JO <br />)wner's Name E---d /4/4q474-727 Phone 3t,-, - <br />Address 1 1 '2.. (..:;," ,,. t..1, . c plinde-c.J e---b- ,-t) /eel) City <br />on JOCIqual Lay LT. <br />:ontractor's Name <br />(Division of Son Joaqdn Suip:iior Ca.) License # 310378 Phono 369-S2 v-7 1 e <br />PIPE OF WORK (Check): NEW WELL /-7 DEEPEN 1-7 RECONDITION / DESTRUCTION /-7 <br />PUMP INSTALLATION / 1 ---PUNT REPAIR ii —PUMP REPLACEMENT <br />Other / / <br />TiSTANCE 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 CO N STRUCTION SPECIFICATIONS <br />InCustrial Cable Tool Dia. of Well Excavation <br /> <br />Domestic/private <br />Domestic/public <br />Irrigation <br />Cathodic Protection <br />Disposal <br />Geophysical <br /> <br />Drilled <br />Driven <br />Gravel Pack <br />Rotary <br />Other <br />Dia. of Well Casing <br />Gauge of Casing <br />Depth of Grout Seal <br />Type of Grout <br /> <br />Other Information <br /> <br />Surface Seal Installed By: <br /> <br />1,JI413 INSTALLATION: Contractor <br />Type of Pump <br />?INT REPLACEMENT: /i-i-tate Work Done <br />'UMP REPAIR: / State Work Done <br />jES.TRUCTION OF WELL: Well Diameter <br />H.P. <br />Describe Material and Procedure <br />I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br />ind 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 <br />,iELL 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 ION <br />'RIOR TO GRO61-11.11S:LAND A FINAL I S Ur, (Division oF Son .l i ocri.n i4ui;)I C).) SIGNED . , TITLE <br /> ( RAW *LOT FLAN -ON REVERSE SIDE) Lodi, Cniktorr'n V4.e.j <br />FOR DEPARTMENT USE ONLY <br />PHASE <br />APPLICATION ACCEPTED BY <br />UDITIONAL COMMENTS: <br />Y9 <br />DATE 1 - <br />PHASE II GROUT INSPECTION <br />INSPECTION BY DATE <br />E H 1426 Rev. 1-74 <br />PHASE III/FINAL INSPECTION <br />INSPECTION BY /7. DATE 3 - <br />0/7/