Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH <br /> DISTRICT <br /> FOF";OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76 7�gkJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) f ffS 130-0e, <br /> Application is hereby made 'to the San Joaquin Local Health District for a permit to construct <br /> and/or install the workllherein 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 *dxld, <br /> r. CENSUS TRACT <br /> Owner's Name i; Phone <br /> _f AOL <br /> Address City <br /> Contractor's Name License # Phone 15'41*2� <br /> Ck <br /> TYPE OF WORK (Check),. NEW WELL -/A-7 DEEPEN.,/? RECONDITION /-" DESTRUCTION /7 <br /> PUMP INSTALLATION / [ `_PUMP REPAIR '/ 7 PUMP REPLACEMENT 17 <br /> .Other - <br />-DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESi <br /> SPIT PRIVY <br /> EWAGE DISPOSFIELD CES POOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF- WELL s ,CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia:_of ,Well Excavation <br /> Domestic/private Drilled"- '}'• 0 <br /> Dia. ,of -Well Casing �. 0� <br /> Domestic/public Driven Gauge of Casing 10 plcj «. d h <br /> Irrigation Graver Pack Dep.fh of Grout Seal a <br /> Cathodic Protection Rotary ` �- .' Type of 'Grout <br /> Disposal Other' " s Other Information <br /> Geophysical, ��. '~'- Surf ace Seal Itistallei $ <br /> h <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP .REPAIR: <br /> /�1/ State Work Done <br /> DESTRUCTION OF WELL: Will Diameter <br /> Approximate Depth k <br /> Describe Material and Procedure <br /> I hereby agree to comply!!kwith all laws and regulations of the San Joaquin'"Local Health District <br />-and the State of California pertaining to or regulating well '�constructivn, Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin, tocal Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the.:we1l_. n.use-... .The above <br /> information is true to. the.best ,of.my-knowledge and belief. i WILL CALL.FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FNAs. INSPECTION. <br /> SIGNED TITLE <br /> '1N (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> �9 FOR DEPARTMENT USE ONLY <br /> AP ATION' ACCEPTED : <br /> ADDITIONAL COMMENTS: :..—DATE.- <br /> PHASE II GROUT,,INSPECTION ---'PHASE-VIII FINAL INSPECTION <br /> INSPECTION BY 11 - DATE l C INSPECTION BY DATE P -A ,6 <br />_-=IE H-1426 Rev. 1-74 __ <br />