Laserfiche WebLink
USAN JOAQUIN LOCAL ,HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `7 <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 Distoict .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 tle San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I� CENSUS TRACT <br /> t } <br /> ( Owner's Name �� - '' r Phone - Z <br /> 1 I _ <br /> Address <br /> Citysr� <br /> Contractor's NameLicense #02� ��Phone `7 �/7 <br /> TYPE OF WORK -(Check) : NEW WELL DEEPEN ''//-/ RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL. FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE RIVATE DOMESTIC WELL 9�W PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ' Industrial Cable Toot ]Dia'. of Well Excavation <br /> Domestic/private Drilled Dia.' of Well Casing _ /a kx _ <br /> Domestic/public ,/Driven Gauge of Casing <br /> x Irrigation - .,Gravel Pack Depth of Grout Seal ^1 <br /> Cathodic Protection " ' Rotary Type of Grout <br /> Disposal Other . Other Information <br /> ' <br /> Geophysical " + Surface Seal Installed By: 4/ _ <br /> PUMP INSTALLATION: Cont,/actor <br /> Tyd of Pump '� -,�.�rs-.%/� -- H.P. _ y <br /> PUMP REPLACEMENT; / / State Work Done i <br /> mak•` ""} <br /> PUMP .REPAIR: / /.State Work Done <br /> DESTRUCTION OF WEL IlWell Diameter `L2Approximate Depth 40 <br /> .I Describe Material and Procedure <br /> rI 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'-constiuction. Within FIFTEEN. DAYS <br /> after completion of myi�work �on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL' DRILLERS REPORT of the'iwell and notify them before putting the. well iThe above <br /> information is true to!lthe est of my knowledge. and belief. I WILL CALL Fn u A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A ZPNAjV INSPECT N. ; <br /> SIGNED -TITL-E--�' . - <br /> �M. (D PLOT PLAN ON REVERSE SIDE) <br /> -� - "FOR •�` * '* � <br /> PHASE I �' 4 <br /> ' APPLICATION ACCEPTED BY ��r.t DATE <br /> ADDITIO�AL- COMMENTS: ---- <br /> - PHASE II GROUT INSPECTILN--- - PHASE III/FINAL, I9SEff5&0N <br /> INSPECTION BY DATE INSPECTION BY.`- - DATE <br /> E H-1426• Rev. I--ir4 - <br />