Laserfiche WebLink
SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOg.OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � _7 1 6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,a 7 <br /> t (Complete In Triplicate) <br /> Application is Aereby 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 �� <br /> �t-off`' CENSUS TRACT <br /> Owner's Name Phone <br /> Address C%!ZP CityLT <br /> .�. <br /> Contractor's Name License ff .9 Phone <br /> ZS 77 <br /> TYPE OF WORK (Check) : NEW WELL/ EEPEN /_/ RECONDITION /-7 DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> 'DISTAN E TO NEAREST: SEPTIC TANK SEWER LINES �'a PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL- CONSTRUCTION SPECIFICATIONS <br /> Indu rial __ ale Tool Dia. of Well Excavation <br /> mastic/private Drilled Dia. of Well Casing /Q -1 <br /> Domestic/public Driven Gauge of Casing / <br /> _L�„J�ation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout Y4, -- <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 /> 4 <br />-PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth1 <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 INSPECTIO <br /> PRIOR TO GR UT AND A FIN PECTIaN. <br /> SIGNED' TITLE > / <br /> tet <br /> (D2gF PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY Q <br /> PHASE I �� � .'�" ''" 1 <br /> APPLICATION ACCEPTED EY DATE <br /> ADDITIONAL COMMENTS: r— <br /> PHASE II PROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ) DATE i INSPECTION BY DATE �, j1 <br /> E H 1426 Rev. 1-74 <br /> 1/77 _ " 2M <br />