Laserfiche WebLink
f �v� <br /> f a SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 371d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 /> r County Ordinance No. 1862 and.' the Rules And Regulations <br /> of. the San J aquin Local Health District. <br /> JOB ADDRESS/LOCATION C% /a it� V � CENSUS TRACT <br /> Owner's Name Phone <br /> AddressCLQ 7L _ Cit <br /> Contractor's Name License #a ^71 hone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION k)Cl DESTRUCTION /_7 <br /> PUMP.IALLATION / I PUMP REPAIR /I / PUMP REPLACEMENT J� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER ES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 450 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ` <br /> INTENDED USE TYPE OF WELL t CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool; _ Dia, of Well Excavation N <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information i <br /> Geophysical Surface Seal Installed BY: i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. j <br /> I <br /> PUMP REPLACEMENT / / State Work Done i <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 1 <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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING A FINA14 INSPE, ION... <br /> SIGNED .TITLE <br /> D W 'I: T PLAN 'ON RE RTE SIDE <br /> !FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE 111-20-174 <br /> ADDITIONAL COMMENTS: <br /> PHASE W9ROUT INSPECTION PHASJIW <br /> F AL INSPECTION/,. <br /> INSPECTION BY DATE INSPECTION BY DATE ; <br /> �tlE H 1426 Rev. 1-74 3/76 2M <br />