Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-64ICE USE: / 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z7R" 10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued as_77 <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/LOCA T NN CENSUS TRACT <br /> Owner's Name ic Phone *- . <br /> Address (�� /�'� City <br /> ff 7� <br /> Contractor's Name License Phone * f}� <br /> X <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7PUMP INSTALLATION PUMP REPAIR gl PUMP REPLACEMENT A-7 <br /> Other <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-�— W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Vf <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 By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: ► j <br /> State Work Done �r F Ca / <br /> i <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 istrict <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 TOTING AND A NAL.I SPECTION. Z <br /> SIGNED ;,.. l t 1 1 TITLEAC�- /( _ C 7 <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY //r!^ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRQUT INSPECTION HAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ;`. DATE�y` ' <;4 <br /> E H 1426 Rev. 1-74 1/77 2M <br />