Laserfiche WebLink
LA <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. '— <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ? ��3,po <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1,0_4_�� <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 /Xa ,�To�quin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address P1.Uj. City <br /> Contractor's Namei � License ftX1. .'2-phone ' _ <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/7 RECONDITION /? DESTRUCTION j <br /> PUMP INSTALLATION/W-7-PUMP REPAIR1_7 PUMP REPLACEMENT /7 <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 Q, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> 'Cathodic Protection Rotary Type of Grout 1 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> DES-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 weil''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..weli in.use.... The above <br /> information is true to the-beat of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO ING AND A VIXAL INSPECTION. <br /> SIGNED TITL <br /> (DRAW PLOT PLAN ON REVERSE SI E <br /> PHASE I FOR DEPARZIENT USE ONLY <br /> APPLICATION ACCEPTED BYDATE �-j}-Z� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASS Uityltm INSPB ON <br /> INSPECTION BY DATE INSPECTION BY E 7 <br /> E H 1426 Rev. 1-74 h/75 2M <br />