Laserfiche WebLink
r I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 70 . OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> :APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a <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 Joaquir <br /> County Ordinance No. 1862 and the. Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRE55y-tft-*T"N €, , X.,-rr.Lj &dWCENSUS TRACT ' - <br /> Owner'sNamed Phone i� <br /> Address <br /> G: City -� - -- <br /> Contractor's Name �� , �/�s�' �' SV/ License ]Phone <br /> TYPE OF WORK (Check) : : NEW WELL / DEEPEN / / RECONDITION /_/ DESTRUCTION / <br /> PUMP INST LL1ATION / PUMP REPAIR / / PUMP REPLACEMENT IV7 <br /> Other IM <br /> DISTANCE TO NEAREST: SEPTIC TANK -)- SEWER LINES ® "PIT PRI-VY <br /> SEWAGE DISPOS�F IELD CESSPOOL/ <br /> LINE VATE DOMESTIC WELL//Q •fPUBLIC <br /> DOMESTIC <br /> INTENDED USE I TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well-Excavation 2 01� <br /> Domestic/private Drilled Dia, of Well Casing . <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> I Cathodic Protectilbn Rotary Type of Grout <br /> k Disposal Other Other Information 11 <br /> Geophysical Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump r I .P. �--. <br /> k PUMP REPLACEMENT: / / State Work Done I <br /> PUMP .REPAIR: State Work none <br /> :- <br /> - <br /> DESTRUCTION OF WELL: '`Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> i 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 we11 'construction. Within FIFTEEN DAYS <br /> after completion of mylwork 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 thewell in use...1 The above <br /> information i5 true tollthe best of my k d e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTI �!Mg <br /> • SIGNED - <br /> 1M W PLOT PLAN N REVERSE SIDE) II <br /> FOR DEPART NT USE ONLY I� <br /> PHASE I <br /> APPLICATION ACCEPTED BY ej <br /> DATE SZ2 IF <br /> ADDITIONAL COMMENTS: 11 jM <br /> r P lgks 4 j I TROUT INSPEC ONPHME/pri/FfNAL INSPECTIO <br /> € INSPECTION BY DATE W' <br /> INSPECTION BY DATE <br /> 2M <br /> E H 1426 Rev. . 1-74 <br /> f%7 <br />