Laserfiche WebLink
CV/ V SAN JOAQUIN LOCAL HEALTH DISTRICT "- <br /> 0-670FF'ICE USE: 1601 E. Hazelton' Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. glyo' � <br /> THIS PERMIT EXPIRES 1 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. 18622 and -the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS ION / - CENSUS TRACT <br /> Owner's Zdo <br /> Phone • r-> <br /> Address <br /> Contractor's Na ZWL;�� <br /> � 4 <br /> License hone'7Z <br /> � r <br /> TYPE OF WORK (check); NEW WELL / . DEEPEN'/-' RECONDITION /_7DESTRUCTION /f <br /> PUMP INSTALLATION -/ 7; PUMP REPAIR I-7 PUMP REPLACEMENT <br /> Other <br /> L/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER , <br /> PROPERTY LINE - PRIVATE -DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial r .-. :� Cable Tool - Dia. of Well Excavation �r <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 <br /> 'r Surf ace Seal Installed 8v <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. � E <br /> PUMP REPLACEMENT: ,' State Work Do ' <br /> PUMP '.REPAIR: Y t •�.��- ..._ __ _ ��__ <br /> /� .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 .bf 'my' knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO GROUTING AND A-.FINAL INSPECTION. <br /> SIGNED TITLE <br /> + V DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I "' :`, <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - .� � ' DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR INSPECTION PHASE III ZINAL INSPECTION <br /> INSPECTION By7MVP�� DATE INSPECTION BY DATE J-3 --2 7 <br /> E H 1426 -Rev. 1-74 <br />