Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /2-g 11�7 <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 C� �R CJ�I/L'� CENSUS TRACT <br /> '3) <br /> Owner T s Name Mv. 4!, Phone 1EEC <br /> Address City <br /> Contractor's Name 0 r jef/j 61 S License t4hone J�/=_72f29 <br /> TYPE OF WORK (Check) : NEW WELL- DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Q SEWER LINES Q t PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT _ �rJ--OTHER <br /> PROPERTY LIN PRIVATE DOMESTIC WELL-5-42- 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 AZV <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation c Gravel Pack Depth of Grout Seal ���E J �� j- Ns� <br /> Cathodic Protection ' Rotary Type of Grout <br /> Disposal nOther Other Information - <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump i' H.P. y <br /> PUMP REPLACEMENT: / / State Work Done <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 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. J <br /> SIGNED E <br /> LO L <br /> N REVERSE SIDE) <br /> FOR DEP MENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECVION <br /> INSPECTION BY DATE �'7 INSPECTION BY DATE <br /> E H 1426 Rev- 1-74 <br /> 6/77 2M <br />