Laserfiche WebLink
�. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOrs:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> w` <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6-a*3 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4_.2L- <br /> (Complete <br /> _.2 -(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 IL' ,� 6, CENSUS TRACT <br /> Owner's Name W- 4 Phone <br /> Address G / f�= = City <br /> Contractor's Name � � License Phone <br />- TYPE OF WORK (Check): NEW WELL /g DEEPEN/_T RECONDITION /—T DESTRUCTION %f <br /> PUMP INSTALLATION / / PUMP REPAIR/7 PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS 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 rr�j <br /> Domestic/public Driven Gauge of Casing 12 <br /> �1 <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: _ /-7 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 G#RUTIIG AND A UK PECTION. <br /> SIGNED / TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY c DATE <br /> ADDITIONAL COMMENTS: <br /> P E II G UT INSPECTION, PHAS F AL INSPECTIO <br /> INSPECTION BY. DATE INSPECTION BY DATE _7771//t241 <br /> E H 1426 Rev. 1-74 h/75 2M <br />