Laserfiche WebLink
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"� Permit No. >6_ Z2ff- l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE JSS D 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 iris made in compliance with San Joaquin <br /> County Ordinance No. 1862.-and the Rules a d Regulations of the San Joaquin Local Health District. <br /> . z6D �a� � <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name l Phone -V77- t�'470Y' <br /> Address /0 Q City <br /> Contractor's Name % d/ License it, Phone <br /> r <br /> i <br /> TYPE OF WORK (Check) : NEW'WELL DEEPEN/ / RECONDITION /� DESTRUCTION /7 l <br /> PUMP INSTALLATION /_/ PUMP-REPAIR '/ / . PUMP REPLACEMENT /7 i <br /> :• Other / -/•._ �" - - - <br /> DISTANCE TO'NEAREST: SEPTIC.-TANK , `SEWER LINES'- -t - - 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 Dia. of Well Excavation <br /> Domestic/private W Drilled Dia.._o.f Well Casing <br /> V 'bomestic/public Driven Gauge-o£ Casing <br /> =Irrigation Gravel Pack ".Depth,of Grout Seal <br /> \ Cathodic Protection _ Rotary , Type of;Grout ' -e--r) >' .. <br /> Disposal Other Other-Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor A e4ZZ2 -- "� <br /> Type of Pump - ` l f-H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 /> after completion of my .work on a new well, I 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 <br /> information is true to the best of-my knowledge and belie£. -I.-WILL- CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUT GAN'jh4 FIN4g INSP ION. <br /> SIGNED - - T�fiLE <br /> (DRAW PL°T' PLAN 'ON RE WRSE.-SIDE.) °'' <br /> FOR DEPARTMENT USE ONLY . <br /> PHASE I <br /> APPLICATION ACCEPTED BY DAT <br /> ADDITIONAL COMMENTS: <br /> P ._ I G UT INSPECTION PHASE /FINAL INSPEC ION . <br /> INSPECTION BY DATE 7/ INSPECTION BY DATE (-�7 <br /> ,,FE H 1426 Rev. 1-74 <br /> 3/7 <br />