Laserfiche WebLink
(0 M.�)o 4�` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 'OFFICE USE,: 16t}1 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.T�_ <br /> �Ae.^e d •e +Joie? Q+�� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 7l'/ wi! I 1 ur dogs• <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. <br /> JOB ADDRI3SS/LOCATION 1 '7 ` CENSUS TRACT <br /> Owner's Name + Phone _ ) 31- <br /> Address l-Address City <br /> Contractor's Name License # /137i4 Phone 1 7a74 <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN -/7 RECONDITION /? DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR —/—/ PUMP REPLACEMENT 17 <br /> Other /—/ <br /> — <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 /> ��C Domestic/private Drilled Dia. of Well Casing { <br /> _- Domestic/public Driven Gauge of Casing <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: Contractors - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: X State Work Done <br /> PUMP,:REPAIR: � <br /> /� State Work Dane <br /> ES-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 DRILLERS REPORT of the well and notify them before putting the-well in .use.. The above <br /> information is true to the-best orf kno ledge d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIO� R T' TING AND A FINAL IN I <br /> SIGNED" <br /> La <br /> !TLE <br /> W PLOT PLAN ON WRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C , DATE <br /> ADDITIONAL COMMENTS <br /> V2-4z�-- <br /> PHASE II GROUT INSPECTION PHA FIN INSPE ION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />`� E H 1426 Rev. 1-74 1-74 2M <br />