Laserfiche WebLink
LA <br /> 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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a�7� <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 of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION i `, i`i'c1 �` ` /� CENSUS TRACT <br /> Owner's Name Phone <br /> Addressi �� ' c- 7 Citp <br /> Contractor's Name - �� -s <br /> �� / W/-"�d ,l 1- x ✓I License # & G t� �. Phone':'- <br /> TYPE OF WORK (Check): ,NEW WELL iff DEEPEN -/7 RECONDITION /7 DESTRUCTION r7 <br /> PUMP INSTALLATION �� PUMP REPAIR /_7 EM <br /> PUMP REPLACENT <br /> Other Lam' <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 e <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 L <br /> Cathodic Protection Rotary Type of GroutF_�y7"G(�// <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed Bvt y ; <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUMP '.REPAIR: /? State Work Done <br /> ,OBSTRUCTION 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 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 well in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ,r :46TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTE B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE - r INSPECTION BY DATE 3 74x" <br /> E H 1426 Rev. 1-74 1-74 2M <br />