Laserfiche WebLink
• �``"` SAN JOAQUIN LOCAL HEALTH DISTRICT G� <br /> FOR OFFICE USE: 1,601 E. Hazelton'Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 2 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 10-V-77 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> I 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. f <br /> JOB ADDRESS/LOCATIONI �/� <br /> rSUSZCT <br /> Owner's Name ---, Phone <br /> s r i <br /> Address ry iv C- City 'rRALCY/ <br /> Contractor's Name License , hone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / DESTRUCTION /_7 <br /> PUMP INSTALLATION M PUMP REPAIR / / PUMP REPLACEMENT <br /> 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 <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 <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor -, A e <br /> Type of Pump u H.P. -�- - <br /> PUMP REPLACEMENT: -! <br /> State Work Done � <br /> PUMP REPAIR: / / State Work Done r <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 Distract <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 t <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 UTING AND A FI A NSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ! <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION_ " <br /> INSPECTION BY DATE INSPECTION BY 41'11� DATE /j -7- <br /> E H-142.6 Rev. - I-74 . 0/77 oar <br />