Laserfiche WebLink
FOR OFFICE' USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209)' 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, YI -//7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,g <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/LOCATION CENSUS TRACT <br /> Owner's Name cam, Phone <br /> Addressl x(33 /� <br /> _ � City � n <br /> Contractor's Name .)&ejL-11 lieLicense �� ( (,1, /Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/-7 RECONDITIO�NI-/-7 - DESTRUCTION /7 <br /> PUMP INSTALLATION REPAIR /1,� PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST SEPTIC TANK 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 Cable 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 Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface 5ea1 Installed B <br /> PUMP INSTALLATION: Contractor ft, <br /> Type of Pump H.P. 1 <br /> PUMP REPLACEMENT: / / State Work Done I <br /> PUMP °.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local. Health istrict <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 DRILLER$ REPORT of the well and notify them before putting the..well in use. The above <br /> information sue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G A'FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ;ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �pdi1 <br /> APPLICATION ACCEPTED BY. —.� DATE 9 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY D. TE ' - <br /> -1 W) <br /> E H 1426 Rev. .1-74 <br /> 177 _ <br />