Laserfiche WebLink
-- � SAN JOA.QUIN LOCAL HEALTH DISTRICT <br /> FOR rOFFICE USE: 1601 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 XEAR�-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. I <br /> JOB ADDRESS/LOCATION J1Dsix MZ2 Lc LL AVLCENSUS TRACT <br /> Owner's Name IQPhone f <br /> Addresscity S <br /> ti <br /> Contractor's Name , License # o220/OPhon;e <br /> TYPE OF WORK (Chdck) : . NEW,-WELL /_7 DEEPEN /? RECONDITION /_7 DESTRUCTION f j <br /> PUMP INSTALLATION / / PUMP REPAIR 171 , PUMP REPLACEMENT /7 .� <br /> Other /J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q <br /> PROPERTY LINE_ L PRIVATE-DOMESTIC WELL PUBLIC DOMESTIC WELL o6 . <br /> INTENDER USE TYPE OF WELL CONSTRUCTION _SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> 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 j <br /> Disposal, Other Other Information j <br /> Geophysical Surface Seal Installed By: i <br /> PUMP INSTALLATION: Contractor <br /> -* Type of Pump H.P. a <br /> PUMP REPLACEMENT: State Work Done <br />" PITMP:REPAIR: = T `}fir State Work Done I .� cS1 -= j � - - L "- <br /> ESTRUCTION OF WELL: Weil 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- thewell in.use.. The above <br /> information.-is true. to the-beat of my knowledge and belief.--I- W`Iff'_CALE_FOR 'GROUT INSPECTION <br /> PRIOR TO GROATIIIG APDA&INAL INSPECTION. <br /> SIGNED 1,41,4 TITLE <br /> {DRAW PLOT PLAN ON REVERSE SPHASE I IDE) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTER BY DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHAS9 UTFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> } ;µE H 1426 Rev. 1-74 w ' 1_71. W i <br />