Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE'USE: 1W 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.. Z- <br /> THIS PERMIT•-EXPIRES 1 YEAR FROM DATEISSUEDDate Issued .20 - <br /> 4 - ,2 <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 Jpiquin .- <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION R CENSUS TRACT <br /> Owner's Name Phone <br /> Address r.'r_'C , 0� — J`r f?�`1� it J City �I <br /> Contractor's Name _ License 4� Phone�j2� <br /> 00 Pd <br /> f TYPE OF WORK (Check) : NEW WELL C DEEPEN /_/ RECONDITION /� DESTRUCTION <br /> 4 PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK ZkgSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC,WELL ' PUBLIC DOMESTIC WELL Q <br /> t INTENDED USE TYPE OF WELL �. CONSTRUCTION SPECIFICATIONS j <br /> j Industrial Cable Tool ,� Dia. of Well Excavation <br /> ''Domestic/private Drilled Dia. of Well Casing 'f D <br /> Domestic/public Driven " ' Gauge of`Casing�..� /62atd. <br /> Irrigation Gravel' Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary, Type of Grout 4 _ <br /> Disposal Other Other Informationf <br /> Geophysical V Surface Seal Installed By/�-'max <br /> PLSMP INSTALLATION: Contractor <br /> Type of-Pump I H.P. <br /> PUMP,-,REPLACEMENT: /% State Work Done <br /> PUMP .REPAIR: ' / / State Work Done <br /> g-S-TRUCTION OF WELL: Well Diameter: ti "` Approximate--Depth _,_-_ <br /> t Describe Mateiial'and Procedure Y <br /> i hereby agreelto comply with all laws and regulations of the San Joaquin Local Health`bistrfct <br /> apd the State of California pertaining to or regulating well "construction. # Within FIFTEEN DAYS . <br /> aftex 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 y, <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 /> (D PLOT PLAN ONREVMRSE SIDE, <br /> DEPARTMENT USE ONLY ' ! <br /> PHASE I i <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHAS4 II INa INSPECTION <br /> INSPECTION BY ; DATE INSPECTION BY DATE 6 . <br /> RX X <br /> /V A)v P P <br /> E H 1,426 Rev. 1-74 A).Q <br />