Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT1 S <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> - <br /> Telephone : (209) 466-6781 ��,-177 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit N6. <br /> i <br /> / 3 <br /> THIS PERMIT EXPIRES 1, YEAR_FROM DATE ISSUED Date lssuedf�2r7 ! <br /> 3 <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. 1.$62 and the Rules and Regulations o£ /the San Joaquin Local. Health,District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> v �Q ✓ -y1�O�a <br /> Owner's Name 6-G[.-!. h ex Phone -- --- <br /> Address3 0i C ✓ City <br /> � � - <br /> ' License # 72t1 Phone *76 <br /> Contractors Name <br /> - 1 <br /> TYPE OF WORK (Check) : NEW WELL / ./ DEEPEN /_./ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / (f 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 cc.. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done _ <br /> PUMP .ISR: / State Work Done -a r / A/ <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 Sats. 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 o knowledge-and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND A FIN S T N. <br /> SIGNED TITLE _ �• -- _ <br /> IV (D14W PL AN ON R ' RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY u ��� DATE fJ - <br /> ti ... 2M <br /> EWH 1426 -Rev: -1-74 <br />