Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 70T.OFFICE USE: �� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 7A 9 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. i� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X76 <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. X1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION T �� A-vt CENSUS TRACT <br /> Owner's Name r--- Phone 3 <br /> Address ,S'9�� City <br /> Contractor's Name License #/4,.,) Phone,? <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN -/-7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other f/ <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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump by" H.P. - L <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP`REPAIR: )9�- State Work Done /p4-!q <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 anew 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 ue to the b st of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU A F INSPEfTION. <br /> SIGNED TITLE _ <br /> RAW PLOT PLAN ON REVERSE-`SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE If GROUT INSPECTION PHASE ;III FINAL INSPBCTT N <br /> INSPECTION BY DATE INSPECTION BY DATE Z '1 <br /> E H 1426 Rev. 1-74 4175 2M <br />