Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP OFFICE USE: 1601 E. Hazelton Ave. Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7]- 6-Zd�t/' <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued S` 3l-7 7 <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe 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 an Regulations of the San Joaquin Local Health District. , <br /> JOB ADDRESS/LOCATION71?f aCENSUS TRACT <br /> Owner's 'Name . <br /> Phone <br /> 4-7 &jAddress City <br /> Contractors Name License #Q /Phone . <br /> TYPE OF WORK (Check) : NE41 WELLDEEPEN / / RECONDITION -/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> I� sS Other <br /> DISTANCE: TO `.NFIAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> � f SEWAGE DISPOSAL FIELD ,--CESSPOOL/SEEPAGE-UT SER <br /> }`<<a PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL t <br /> INTENDED,�USE TYPE OF WELL CONSTRUCTION SPECIFI TIONS <br /> Indusirial able Tool Dia. of Well Excavation <br /> Do6esti:&,�%private 1 Drilled.,_-- Dia. of Well Casing <br /> P <br /> Domestic)/Public Driven, -- �-=Gauge�of- Casingi <br /> �rigatibn # Gravel 'Pack Depth of Grout Seal .--- T <br /> Cathodic-Protection 1 Rotary Type of Grout ---- <br /> Dis osal� 1 Other Other Information ' <br /> r Ir <br /> Geophysip-aT Y Surface Seal Installed By: <br /> r PUMP INSTALLA`PI0N: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .RERAIR�: / / State Work Done ' <br /> k' <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 /> I and the 'State of California pertaining toLor jir gula-ting well construction. Within. FIFTEEN DAYS <br /> after comp le on�of"'m -work�on a new'well,"I wiiltifurnish the San Joaquin Loca1N'Health District a <br /> WELL DRILLERS REPORT of the well and notify ''them before putting t' e: l.wel 'zn= �-- <br /> use: The above <br /> information_'_ t ue to the best a _my knowle ge and belief. I WILL CPL <br /> FORA GROUT ,INSPECTION <br /> PRIOR TO GRO T <br /> SIGNED <br /> ` i D WL T"PL RE FRSE SIDE) <br /> FOR DEPART T USE ONLY <br /> PHASE s ,.� <.,r5=" N, <br /> APPLICATION; ACCEPTED BY` DATE 1 <br /> ADDITIONAL iCOMMENTS: _ z7v <br /> I PHASE II GROUT TNSPECTIONj PHASE-'III/FINAL=XNSPECTIg_N <br /> INSPECTION BY DATE INSPECTION BY ' DATE <br /> E H 1426 Rev. 1--74 <br />