Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�:OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (las) 466-6781 Y ` <br /> 1s <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE1ISSUED Date Issued S`- - 7 <br /> {Complete In Triplicate) <br /> Application is hereby made to the San JoaquTct <br /> hiLso�allHealth <br /> at on District <br /> de inrcompliance twith SanJoaquin <br /> and/or install the work herein described. pp <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> /VOCATION c� 7)/ f- • Ldp <br /> JOB ADDRESS <br /> CENSUS TRACT <br /> . - Phone <br /> Ownerts Name s <br /> City uILr`' <br /> Address <br /> Contractor's Name ,d� , License-#o��d�,# Phone ��� <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN I? RECONDITION f7DESTRUCTION <br /> PUMP INSTALLATION El MP PUMP REPAIR'/7 PUREPLACEMENT A <br /> Other E7 <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 9 <br /> Industrial - .-77--:--Cable Tool Dia. of Well Excavation �V <br /> Domestic/private Drilled Dia. of. Well Casing_. \ <br /> Domestic/public Driven Gauge of Casing <br /> .Irrigation Gravel Pack ­Depthof Grout Seal- <br /> Cathodic Protection Rotary Type of Grout <br /> DisposalOther Other Information' <br /> Geophysical .^.�_ — Surface Seal Installed By: <br /> PUMP INSTALLATION: n Contractor <br /> .Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done 1?ArkXjV1_. <br /> Y PUMP '.REPAIR: / 7 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 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 GALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROU NG ANDA IN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN. ON REVERSE SIDE P_d0_ZL <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IATE 6 <br /> i APPLICATION ACCEPTED BY DATE �" <br /> ADDITIONAL COMMENTS: p I g� INSPECT ON <br /> PHASE 11- GROUT INSPECTION c <br /> INSPECTION BY DATE INSPECTION B , DATE <br /> 2M <br /> I E H 1426 Rev. 1-74 <br />