Laserfiche WebLink
FOF SAN JOAQUIN LOCAL HEALTH DISTRICT '7"/ <br /> .-"> <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No-7 <br /> 17 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued������ <br /> 37 <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 Jo4quin <br /> County Ordinance No. 1862and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/ 8N '�/'Z Q !f � _-j // <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> city , ®, <br /> Contractor's Name <br /> License hone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN _ <br /> ' / / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / _ <br /> DISTANCE TO NEAREST: SEPTIC TANK ' <br /> /�C SEWER LINES�e9 ,4-PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 166 ¢-CES PIT <br /> PROPERTY LIN624RIVATE DOMESTIC WEL /--pUBj <br /> TYPE OF WIC DOMES <br /> THER <br /> INTENDED USWELL <br /> E ELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation f <br /> Domestic/private _ Drilled -- -'- <br /> Domestic/public DDia, of Well Casing T <br /> Irrigation riven Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary T <br /> Disposal Type of Grout <br /> Other Other Information <br /> Geophysical -- <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor � / <br /> Type of Pump 4 <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 thewell in use.. The above <br /> Lnformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AND A FINAL INSPECTI <br /> iIGNED � c �00, � <br /> E <br /> W PL L ON REVERSE SIDE) <br />'RASE I FOR DEP TMENT USE ONLY <br /> APPLICATION ACCEPTED BYp <br /> JDDITIONAL COMMENTS: DATE --= J/ <br /> PHASE II GROUT INSPECTION <br /> NSPECTION BYPHAS /F NAL INSPECTION <br /> s DATE INSPECTION BY <br /> DATE <br /> E H 1426 Rev. 1-74 _ 1 /77 ,�� <br />