Laserfiche WebLink
r! lei <br /> �.r T <br /> SAN JOAQ LOCAL HEALTH D STRICT <br /> FOF� OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. r <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 <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 /> JOE ADDRESS/LOCATION _.ZZ 67 E " CENSUS TRACT tt <br /> Owner's Name t . /l� P Phone ' <br /> Address City <br /> Contractor's Name e Licens U SPhone3 <br /> TYPE OF WORK (Check); NEW WELL/Z7 -DEEPEN 'j'7 RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION /,!7 SUMP REPAIR/ / PUMP REPLACEMENT j? <br /> Other %j 3 <br /> DISTANCE TO NEAREST: SEPTIC TANK IL10 SEWER-LINES PIT PRIVY ; <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL } <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial: . L- -table 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 SealC <br /> Cathodic Protection Rotary Type of Grout , <br /> Disposal Other . Other'Information <br /> Geophysical Surface_S.eal .Install,ed 'B <br /> J ,f <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump '' ,, H.P.- <br /> �- <br /> PUMP REPLACEMENT; , / / State Work Done {� j <br /> PIE .REPAIR: / / State Work Donee <br /> DESTRUCTION OF WELL: Well. Diameter <br /> ' 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 wellj'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 f <br /> information is true to- the-best -of- my knowledge and belief. I WILL CALL FOR-A -GROUT INSPECTION <br /> PRIOR TO GWaE ANDA FIN NSPECTION. <br /> SIGNED TITLEt <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i -- <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS: h <br /> PHAU II GROUT INSPECTION PHASE gI FINAL INSPECTION <br /> INSPECTION BY DATE ]CNS EC ION BY DATE Q z <br /> . <br /> - :--,-E H 1426 Rev. 1-74 1 /�� .2M <br />