Laserfiche WebLink
_ SAN JOAQUIN LOCtrL'HEA�,TH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 94 3 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L " <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 ` <br /> oaquin Local ealth District. _ <br /> JOB ADDRESS/LOCATI6 ' CENSUS TRACT <br /> i / <br /> Owner's Name C 164? A 0a u� _ Mri t.L L. k Phone <br /> Address I-ld� 1 S: l j ► �rvL City A. &Cc Hca .t <br /> Contractor's Name }� ,� „� �; ��p,. License Phone:I ' -31,"- <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION/ '/ PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Other i/ FRA vkp SF_, we'll <br /> - DIISTANCE 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 /> k _ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor W"ov'e. d►w^1;^'V%c E ('c <br /> Type of Pump `r H.P. 4yp <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 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 TITLE ;-ccs <br /> (DRAW PLOT PLAN ON REVERSE SIDE) r . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE T /FIN INSPECTION �y <br /> INSPECTION BY DATE INSPECTION BY DATE — --Z <br /> E H 1426 Rev. 1-74 <br />