Laserfiche WebLink
-T-61"OFF E USE: SAN JOAQUIN- LOCAL HEALTH DISTRICT "� ���w _ � 5_/ <br /> IC1601 E. Hazelton Ave. , Stockton, Calif. ! / 3 3�7 <br /> Telephone: (209), 466-6781 <br /> APPLICATION FOR WELLN CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Z.7- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/u" <br /> CENSUS TRACT <br /> Owner's Name �I <br /> Phone <br /> Address - � � '� 6 • � City <br /> � <br /> Contractor's Name <br /> License Phone ,. fa <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN '/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION/W PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / / T`- r <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWERLINES , <br /> „t-, `Q �m `P iT-PRIVY .� +'� : <br /> ... .x.�..-SEWAGE-DISPOSAL—IELD� ._ CESSPOOL/SEEPAGE`P_IT ''" I <br /> S f ?�'QT-HER � <br /> PROPERTY LINL�� PRIVATE DOMES TIC•_WEL2`PUELIC bOMESTIC WELL%da# <br /> INTENDED USE TYPE OF WELL <br /> r CCONSTRUCTION-SPECIFICATIONS <br /> Industrial Cable Tool / , Diidof Well Excavation'_ �' ! <br /> Domestic/private , Drilled _. - <br /> Dka l of Well�' acing: ° <br /> Domestic/public Driven � Gauge of Casing I "� �`+ �, ' <br /> Irrigation '� A <br /> g Gravel Pack Depth,-of Grout Seal A_., t <br /> Cathodic Protection Rotar Type T _ <br /> —. Y T e of Grout .� k <br /> Disposal Other �' -, __ _ f <br />—Geophysical---__._ Other_Inforatio„n <br /> � Sur Face-_Seal-Installed. B :_ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> r 'C H.P. <br /> PUMP REPLACEMENT; / / State Work Done <br /> r <br /> PUMP .REPAIR: t <br /> State -Work Done <br /> DES ,,_CTION OF WELL,. Well Diameter w <br /> Approximate Depth � E <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.knowled a and belief. I WILT, CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION <br /> SIGNED <br /> TITLE <br /> (DRAW PL' T' PL ON REVS <br /> FOR DEP TMENT. USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY d5;, "- DATE S �� <br /> ADDITIONAL COMMENTS: - _ <br /> PHA I GROUT*INSPECTIO ����HASE I/FI AL INSPECTI <br /> INSPECTION BY DATE__._.__ ¢- �-INSPECTION BY <br /> DATE <br /> E H 1426 Rev. 1-74v a j 3/76 2M <br /> �c <br />