Laserfiche WebLink
G 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 16� <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 Joaq in Local Health District. <br /> JOB ADDRESS/LOCATION <br /> arL, � W6?4ENSUS TRACT <br /> tw a <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License hone 4 <br /> i <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN/ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/—/ PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 10 0 SEWER LINES PIT PRIVY <br /> SEWAGE DISP AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /49 <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 :JE Rotary Type of Grout <br /> HOC- <br /> Disposal Other Other Information <br /> Geophysical p� Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 14;7 <br /> Type of Pump 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 <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distric <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 GROUTIW, AND AFINAL SPE ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON RE IRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ,APPLICATION ACCEPTED BY DATE —74� 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE s 1, {# <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />