Laserfiche WebLink
- s <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT n <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. ' <br /> I �x <br /> THISiPERMIT EXPIRES 1 YEAR FROM DATE ISSUED. " Date Issued X9an- -V <br /> (Complete In Triplicate) � <br /> Application is'Aereby made to the San Joaquin Local Health District for a` permit to construct' <br /> and/or install the work hereinRdescribed. 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 /> 17-7—5PO-- Zv <br /> JOB ADDRESS/LOCATION C SUS TRACT <br /> Owner's Name one S�V3q. - -2 C7&2 <br /> Address City , <br /> J <br /> ity ,J <br /> Contractor's Name License # Phone <br /> t <br /> eh <br /> TYP OF WORK (Check) :. NEW WEL4; DEEPEN / / RECONDITION / / DESTRUCTION /—j <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other , /7/ <br /> DISTANCE TO NEAREST: SEPTIC TANK �-tSEWER LINES ,+ PIT PRIVY <br /> NiSEWAGE 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` I Cable Tool Dia. of Well Excavation <br /> Domestic/private A Drilled _ Dia. of Well Casing /� D <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation ; . + ` Gravel Pack- Depth of Grout Seal L= / <br /> Cathodic+Protection A Rotary `M Type''o' -Grout. <br /> Disposal Other Otherj Information, 1 <br /> Geophysical Surface Seal Installed. B <br /> . , <br /> PUMP INSTALLATION: Contractor . - <br /> M <br /> -Type of Pump r H.P. <br /> 1Y <br /> PUMP REPLACEMENT: / / State Work Done f. ar <br /> PUMP.-REPAIR.:_-_.-- �>.�,�;://�5.ta.te 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 regul'ations"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 'giiutting-,the well in use. The above <br /> information is. true to the best of my knowledge and belief 7 I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROVIING SAND AL INSPECT IO <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT-PAY ON REVERSE SIDE)- <br /> FOR DEP TMENT USE ONLY <br /> PHASE I ' } <br /> APPLICATION ACCEPTED BY �t, DATE <br /> ADDITIONAL COMMENTS: 6--f4--pe <br /> PHASE II GROUT INSPECTION -- PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 9-7� Y INSPECTION BY � DATE i S'-' <br /> E H 1426 Rev. 1-74 <br />