Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> } Telephone: (209) 466-6781 <br /> k APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,-Ik-fp 7/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued `L:3--76 <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> G JOB ADDRESS/LOCATION7 CENSUS TRACT <br /> Owner's Name Phone � <br /> AddressCit <br /> S <br /> y <br /> Contractor's Name , License # Phone -05 <br /> TYPE OF WORK (Check): NEW WELL.-L-7 DEEPEN -/-7 RECONDITION /7 DESTRUCTION /- <br /> PUMP INSTALLATION/_/ PUMP REPAIR/77 PUMP REPLACEMENT /7' <br /> Other /% <br /> t — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> E SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER U <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 /> E Cathodic Protection Rotary Type of Grout <br /> Disposal Other . Other Information <br /> Geophysical _ � Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. : <br /> PUMP REPLACEMENT: . / / State Work Done <br /> 1 PUMP REPATR: _^n'.. ,....;� -State Work Done"_. <br /> IlE&TRUCTION 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 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-of-'my..knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR Dy <br /> MTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ` DATE <br /> ' ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION P E I INAL INSPEMO /Zi/ <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-76 rJ 1.t7c d3U <br />