Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO OF7ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Teiephone: (209) 466-6781 <br /> 1d APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71,5%G r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -33-7 <br /> (Complete In Triplicate)* <br /> Application is hereby made to the San Joaquin. Local Health District for a permit to construct <br /> ' and/or inst-ll 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 /> JOU ADDRESS/LOCATION %�j(r �� `, V:I J� NF(Z l �/)L1 CENSUS TRACT <br /> ( n, <br /> Owner's Name f}1 }�, _,�j //�/ �') _ Phone 1 --3/11;19 <br /> Address _� f„ City Aj.QnitJ <br /> Phone <br /> License Contractor s Name 1 1 i, c f`�,.-� License // ,2 <br /> TYPE OF WORK (Check) : NEW WELL ./ / DEEPEN /_/. _RECONDITION %/ DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION /_/ DUMP PEPAIR /_/ PUMP REPLACEMENT <br /> Other <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 /> Industrial Cable Tool Oia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection. Rotary iype..of Grout <br /> Disposal Other Other Information _ <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. _ <br /> F'JAfP REPLACEMENT: State Work Done K v - 7- <br /> PUMP <br /> PUMP REPAIR: State Work Done _ n <br /> DESTRUCTION OF WELL: Well lli.ameter _ _ Approximate Depth (� <br /> Describe Material and Procedure <br /> I ',.?reby agree to comply with e:.11 laws and regulations of the San Joaquin Local Health District <br /> State of California pertaining to ,n regulating well construction. Within FIFTEEN DAYS <br /> impletion of my work on a new well, I will furnish the San Joaquin Lrzal Health District a <br /> _LLERS REPORT of the well and notify them before putting the well in use. The above <br /> ,pion is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRM: FO GROU1 NG AND A NAL T,NSPECTION. <br /> SIGNED TITLE- <br /> (CRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> V <br /> PHASE I / <br /> APPLICATION ACCEPTED BY / DATE <br /> Pr <br /> ADDITIONAL CO,.MENTS: <br /> PHASE II GROUT' IN'SPECTI_ON PHASE II /FIDIAI, INSPECTION <br /> INSPECTION BY DATE INSPECTIG, BY 1 / DATE <br /> 1177 . 2M <br /> E ti 1426 Rev. 1-%4 <br /> y <br /> M <br />