Laserfiche WebLink
/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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;R! s and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 7V CENSUS TRACT/Mo e� -' <br /> Owner's Name pC Phone ^ — <br /> �lq <br /> Addresscp2L <br /> City 2"670-: Z42, Cd1_ <br /> Contractor's Name 1 License . 3 Phone gy <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / CONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /-7 -Z' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK/ SEWER L�NES p v PIT PRIVY <br /> SEWAGE DISP SO AL FIELD`S CESSPOOL/SEEPAGE PIT/ OTHER ^---* 4. <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL —PUBLIC DOMESTIC WELL n <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �mestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing -- <br /> Irrigation Gravel Pack Depth of Grout Se 6 <br /> Cathodic Protection teary Type of Grout _ v <br /> Disposal Other Other Information -- p <br /> Geophysical Su a Seal Installed By: P <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure —rte <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 a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well an notify them before putting the well in use. The above <br /> infor on is true to the bes y owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T G UTING AND A F S IO <br /> dAt <br /> SIG t TITL MA. , <br /> PLOT PLAN ON REVERSE S <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: tz <br /> PHASE II GROUT INSPECTION PHASE, III/FINAL INSPECTION <br /> INSPECTION BY A:.," DATE - ¢j '-7P INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 ` <br /> 1f77 2H <br />