Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE. !/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 110 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued lv as-74 <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 /> and Re ations of the San Joaquin Local Health District. <br /> County Ordinance No. 1862 and the Rules <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address Q City <br /> Contractors NameLicense Phone <br /> i <br /> rF' <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION f / PUMP REPAIR -/ I PUMP REPLACEMENT 4 <br /> Other [_7 <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 d <br /> Irrigation GraVel'Pack Depth of Grout Seams <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other` ' Other Information <br /> Geophysical__ <br /> 4 � Surface Seal. Installed <br /> Y, <br />` PUMP"TNSTAZLATTON; Contracto - <br /> ` Type of Pump H.P. <br /> fState Work Don <br /> PUMP REPLACEMENT: / / F _ <br /> OF <br /> PUMP .REPAIR: <br /> State Work Done <br /> I I r <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 Calzfor'nia 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 CADL FOR A GROUT INSPECTION <br /> PRIOR TO k2,WT-kWq_AtM A FIN IN ECT <br /> SIGNEDTITLE <br /> DRAW PT' T PLAN ON RE FRSE SIDE) <br /> -FOR DEPARTMENT USE ONLY <br /> PHASE I 9 <br /> APPLICATION ACCEPTED BY t - i DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE TI GROUT INSPECTION PHAS II IN INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1--74 < , <br />