Laserfiche WebLink
,6 � ,R <br /> SAN JOAQUIN LOCAL HEALTH-DISTRICT UU <br /> -i—­,OFFICE USE: v 1601 E. Hazelton Ave. , Stockton, Calif. ; <br /> / Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 � j <br /> THIS FERMIT EXPIRES <br /> 1 YEAR FROM DATE ISSUED Date Issued _ S-27 <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 /> k County Ordinance N y-862 and the Rules and Regulations of the San Joaquin Local Health District., <br /> JOB ADDRESS/LOCATION , _ CENSUS TRACT <br /> e41 <br /> Owner's Name hone <br /> f City <br /> Address <br /> . Contractor's Name �°d?2� Licensee .ft I/ ' Phone �� <br /> TYPE OF WORK (Check) : NEW WELL PEN—/ / RECONDITION /-7 DESTRUCTION /-] <br /> PUMP INSTALLATION -/!:� -per REPAIR / / PUMP REPLACEMENT j? <br /> a 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 10,7d <br /> z---'Homestic/private iDrilled Dia. of Well Casing <br /> .Domestic/pub{tic' Driven Gauge of. Casing <br /> Xrrigation ;z <br /> Gravel Pack Depth of Grout,Seal <br /> Cahodic�Protection . Rotary Type of Grout S <br /> Disposal Other Other Information ' <br /> Geophysical �^a= Surface Seal Installed B <br /> PUMA 1r9TAEaTION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> ,.._PUMP .REPAIR: j / State Work Done <br /> DESTRUCTION 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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO AND A FINAL INSPECT O . <br /> SIGNED TITLE-, <br /> RAW 'Ph T PLAN ON RE ERSi. SIDE "' �: <br /> FOR._DEPARTMENT•->USE1.ONLY�--5 ; <br /> PHASE I <br /> APPLICATION,ACCLPTED ,BY DATE <br /> ADDITIONAL'.COMMENTS A 11 r <br /> 1 �PHASE .II PHASE III FIN CTI N <br /> GROUT INSPECTION INSPE <br /> NiNSPECTION BY, ✓ °DATE.= -� '�l INSPECTION BY DATE <br /> 3/70 2M <br /> E 1426 Rev. '1-74 <br /> .�. .. <br />