Laserfiche WebLink
C (_ SAN -JOAQUIN LOCAL HEALTH DISTRICT s <br /> 70T ZHICE USE: 1601 E. . Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. x _-..y 3 -4,1 I <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED 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 is made in compliance with San Joaquin; <br /> - County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. j <br /> JOB ADDRESS/LOCATION .3 i�. . CENSUS TRACT <br /> Owner's Name • Phone <br /> Z229 <br /> Address =, c3.+d /�iB7 . ,., HiQ t AA:7 G"T .f6 <br /> .. I <br /> Contractor's Name t License ll !�/ Z Phone <br /> I <br /> TYPE OF WORK (Check) : NEW WELL /!�EEPEN /_% RECONDITION /__' DESTRUCTION f7 } <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT f7 _ <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES ".PIT PRIVY ; <br /> SEWAGE DISPOSAL FIELD"40' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WEL ¢PUBLIC DOMESTIC WELL W <br /> INTENDED -USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial Casale Tool Dia. of Well Excavation Ale <br /> Domestic/private Drilled Dia. of Well Casing Q <br /> Domestic/public Driven Gauge ofCasing <br /> �Irrigation Gravel Pack Depth of Grout Seal <br /> Cpthodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed„By - <br /> . --_- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP !REPAIR: /% State Work Done u <br /> ZES;TRUCTION 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 DRILLERSREPORT of the well and notify them before putting. the. wel.l in use.. The above <br /> information is true to a est-of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU D INSPECT-ION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY tjV741 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONor PRASE III FINAL INSPECTID <br /> INSPECTION BY �°� �T DATE / ' INSPECTION BY DATE' �,P <br /> ,t E H 1426 Rev. 1-74 1_74 9M <br />