Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OF 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209)' 466-6781 <br /> r ICATION FOR WELL CONSTRUCTION OR PUMP .PERMIT Permit No. 5sb-IPsZ <br /> �,,���� THIS PER--- ------------ <br /> MIT EXPIRES 1 YEAR:FROM DATE ISSUED Date Issued b-k1-F�to <br /> Applic .' 4 M" TA HEAUH (Complete In Triplicate) <br /> 1 C de to the San Joaquin Local Health District for a permit to construct <br /> and/or instal h�rk herein described. This application is made in compliance with San etaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION ' <br /> Q _ CENSUS TRACT <br /> Owner's Name LSA ` <br /> Phone <br /> Address U pn City <br /> Contractor's Name � n � ,License # <br /> yN)*'Phone yZ� <br /> TYPE OF WORK (Check) : NEW WELL ` DEEPEN /7 RECONDITION / DESTRUCTION /_7 <br /> PUMP INSTTI ATION / / PUMP REPAIR / / REPLACEMENT <br /> Other <br />`DISTANCE T ". <br /> • NEAREST: SEPTIC TANK SEWER I,,INES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD �/ IAC CESSPOOL/SEEPAGE PIT OTHERI <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC W <br /> INTENDED USE TYPE OF WELL ELL <br /> Industrial CONSTRUCTION SPECIFICAT ONS <br /> 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 Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Q �✓ <br /> Surface Seal Installed B <br /> PUMP_INSTALLATION: Contractor ` <br /> 1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / . 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 San Joaquin Local Health istrict <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 notifythem before <br /> puttingthe. well in use. The above <br /> information is to the b of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GRO NG ' FI SPECTION. <br /> SIGNED TITLE <br /> (D W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY F <br /> PHASE I <br /> APPLICATION ACCEPTED BY Q DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE -7— l �f-G INSPECTION BY DATE <br /> 't, <br /> E H_1426 Rev. 1-74 1/77 9 t <br />