Laserfiche WebLink
' SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> FORrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?S Y?3/0 <br /> w THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued TSS <br /> (Complete In Triplicate) <br /> Applicition�is hereby made to the Sat: 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 . . Q J6wOF t-e,-y CENSUS TRACT <br /> Owner's Name zeP Phone ' <br /> Address " - 07 City <br /> Contractor's Name Licensee Phone ' <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/-7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT / pn <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 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. ' of Well Excavation Qt � <br /> Domestic/private Drilled Dia, of Well Casing r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> v Disposal - Other Other Information <br /> ! Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done � <br /> PUW ,.REPAIR: /7 State Work Done _ <br /> ES:TRUCTION 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 1 <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 wdll and notify them before puttingthewell in use. The above <br /> information is true to the-best of. my.knowledge and belief. I WILL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND NAL INSPECTION. <br /> SIGNEDTITLE <br /> RAW PLOT PLAN ON REVERSE 5I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE •-� 7� <br /> `} E R 1426 Rev. 1-74 1-7.4 2M � <br />