Laserfiche WebLink
fad SAN JOAQUIN LOCAL HEALTH. DISTRICT ` rM4e- *7 <br /> FOH ,OT�FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. k <br /> Telephone. (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 6 a 2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,. Date Issued ? <br /> (Complete In Triplicate) � <br /> Application is 'l�ereby 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 Joaquin' <br /> County Ordinance No. '1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 0 " Cggglo „, CENSUS TRACT <br /> 9700 '/V <br /> Owner's Name o MIC M-6Phone f s <br /> Address City o <br /> Contractor's Name License #,�3,3// Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ J RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /� 1 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC. TANK/ <br /> S� .� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL -FIELD ``` CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL/,5-0—!-/ PUBLIC DOMESTIC WELT, - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial -A_ Cable Tool Dia. of Well Excavation !J <br /> Domestic/private. Drilled Dia. of Well Casing <br /> Domestic/public f Driven Gauge of Casing --- ” <br /> Irrigation : : n. Gravel Pack 'bept �o€ Grout SealUV <br /> Cathodic Protection. Rotary Type of Grout <br /> 'Disposal _ - Other Other Information -- <br /> Geophysical r"� M Surface Seal Installed By: <br /> Pi7MP INSTALLATION: '' Contractors �f -� 0 yr S T/N� 'Lo oo-n A o °` a <br /> Type of Pump „F r H.T•. <br /> PUMP REPLACEMENT: r. / / State Work Done. <br /> PUW-:REPAIR: State Work-Done <br /> DESTRUCTION OF WELL: s Well Diameter Approximate, Aep,th; 1 <br /> _ ., ._ <br /> De�cr-�be--Ma�e�ial and'Pror:ezi�xr�"'�'"""`�_`..� - -�-- • <br /> Ix 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 a <br /> WELL DRILLERS REPORT of the well and notifythem before <br /> putting the well in use. The above <br /> information is true to the. . of`6knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ISIGNE <br /> R T NG A FI NS ON. - t <br /> TITLE , <br /> (DRAW PLOT PLAN ON REVERSE-SIDE) _-._-- <br /> FOR DEPARTMENT USE ONLY t <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P!!ASEIj1/FIN4 INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. _ 1,_-7A <br />