Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> F'Uh:JFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued IV�,,7 7 J7S <br /> (Complete In Triplicate) ` <br /> Application is hereby made to the San Joaquin Local Health District fora 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 W_ ,� 44-1�1 ' CENSUS TRACT <br /> Owner's Name <br /> 3 Phone <br /> Address _� 7_ .,_,..,, __ City <br /> Contractor's Name . License #1(,22,7.3 Phone r <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN -/-7 RECONDITION /7 DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP`REPAIR '.0 PUMP REPLACEMENT /7 <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 Dia. of Well Excavation <br /> Domestic/private DrilJ.ed ' �` Bia:ofWell Casing - <br /> Domestic/public Driven Gauge of Casing i <br /> Irrigation Gravel',Pack Depth of Grout Seal <br /> Cathodic Protection Rotary. Type of Grout <br /> Disposal Other _ - Other Information <br /> Geophysical Surface Seal Installed By; <br /> PUMP INSTALLATION; Contractor <br /> - Type of Pump H.P. /b t <br /> 4�- <br /> PUM REPLACEMENT: . / State Work Done' I <br /> PUMP .REPAIR: / / State Work Done <br /> i <br /> DESTRUCTIONrOF WELL:__Wel1_ 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 t e to the est of my'llAoWledge and belief. I WILL CALL FOR A GROUT IN <br /> PRIOR TO GROUTIWAND A EQrAL INSPECXION. <br /> SIGNED TITLE <br /> 2�� W4tM PLAN 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE `f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION'' <br /> INSPECTION BY DATE INSPECTION BY W. DATE <br /> V7b <br /> E .H 1426 <br /> Rev. 1-74 <br />