Laserfiche WebLink
SAN JOAQUIN�()CAI, HEALTH DISTRICT ��� <br /> FOh.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. O-/T <br /> r/ <br /> THIS -PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) t <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 andthe Rule and Re ulations of the San Joaqin uocal Health District. <br /> //0 ti--!, an 2 L�-�� a /✓ <br /> JOB ADDRESS/LOCATIONi G SIS' CENSUS TRACT <br /> Owner's Name - Phone _5"ffS 7 G � I <br /> Address 7 S. lc;.e,f- J, Cit , <br /> Y �. !J�ir <br /> Contractor's Name40 W"G :a,,� ce License #3�rs7 Phone <br /> ido <br /> TYPE OF WORK (Check) : NEW WELL /' / DEEPEN '/—/ . RECONDITION /_/ DESTRUCTION /_ <br /> AL <br /> PUMP INSTLATION 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 r-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 /> 1l Irrigation 'Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 'Other Other Information ' 4 <br /> Geophysical Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor �.} �f� :a. C_No <br /> __ k <br /> Coxe, � neci <br /> Type of Pump 6, _ �t�.g H.P. <br /> . I . <br /> _ <br /> PUMP REPLACEMENT: /X/ State Work Done <br /> PUMP ,.REPAIR: / / 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 Sats Joaquin Local Health District <br /> and the State,;offCalifornia 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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE __ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE .��� <br /> -- -- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRO T INSPECTION PHASE I; /FIN INSPECTION a <br /> INSPECTION BY /� ^ DATE INSPECTION BYDATE f 7 g <br /> E H -1426 Rev. 1-74 <br />