Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH- DISTRICT , <br /> F0 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z, <br /> II <br /> II THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued /7--74 � <br /> (Complete In Triplicate) y <br /> Application is hereby made to ,the San Joaquin Local Health District for a permit to construct <br /> and/or install the workjjherein described. This application is made in compliance with San Joaquin ! <br /> County- Ordinance No. 1862 and the R nd ations of the an Joaquin Local Health District t <br /> ik C <br /> JOB ADDRESS/LOCAT CENSUS TRACT ' <br /> Owner's Name An Phon <br /> Address City- <br /> Contractor's Name � License I �� hone � <br /> _�_. -�.. -�-i.�� <br /> -TYPE_OF :WORK(Check)_:ANEW,WELL -DEEPEN I I RECONDITION ./_T-_DES_RUCTION__/'?n_-.:. .� �` A <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 - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE I TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I 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 Seal Installed By: <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 1' PUMP REPLACEMENT: . / / State Work Done <br /> i { <br /> PUMP .REPAIR: State Work Do <br /> DE5 TRUCTION_ OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t I� <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 Mork on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT oflthe 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 AND A,IFINAL INSPECTION. <br /> SIGNED v YYti G� p �,, _ TITLE <br /> (DRAW 1°' }T PLAN 'ON MtSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I — - -- <br /> APPLICATION ACCEPTED BY' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II QROUT INSPECTION PHASE I . SINAL INSPECTION ' <br /> INSPECTION BY - , DATE INSPECTION BY DATE • <br /> 6 <br /> E H 1426 Rev. 1-74 ' <br />