Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S�J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> a $� <br /> (Complete In Triplicate) 77 <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' <br /> JOB ADDRESS/LOCATIONr <br /> !"v CENSUS TRACT <br /> Owner's Name <br /> - Y 10(0'r aril!VC Phone <br /> Address41- <br /> U7r h Q + <br /> City <br /> Contractor's Name r <br /> ° License # Phone <br /> i <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN / / RECONDITION DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT-7-7 <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 PackDepth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposl Other Other Information 4 <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR: /_7 State Work Done <br /> RES-T WCTION OF WELL: Well Diameter <br /> �.4proximate Depth <br /> cribe Mate 1 a d Proced reMA <br /> —��- <br /> I hereby agree to "comply -with--a-117,-I:iaws"d-n8 regulations of the San Joaquin ocal Hea th 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.bes,t-ofTmy.-knowled-ge--and-be-ie-f--t-I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G ING 'A AL INSPECTION. <br /> SIGNED N TITLE <br /> JDRAW P T PLAN 'ON RE WE SIDEj <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE yf <br /> ADDITIONAL COMMENTS: <br /> P S I CTIO PHASE III/FINAL INSPECTION <br /> INSPECTION BY A E ZQ$�, INcraECTION BY DATE <br /> E H 1426 Rev. 1-7 b bK awl lo. 3/76 2M <br />