Laserfiche WebLink
r <br /> FOE;OFF'TCE USE: _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Z.5 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) <br /> � Application is hereby made to thh San Joaquin Local Health District for a <br /> permit and/or install. the work herein described. This, application is made in Joaquincompl.iancetwith nSan u <br /> (( FCounty Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Loc <br /> I � <br /> q Local Health District. <br /> JOB ADDRESS/LOCATION <br /> Owner's Name CENSUS TRACT <br /> ' <br /> Phone ' <br /> f Address �U <br /> city . <br /> Contractor's Name <br /> -� License # 7.,��Z_Phone��.1` 597 <br /> I TYPE OF WORK (Check): NEW WELL.'S DEEPEN/_' RECONDITION <br /> PUMP INSTALLATION / / PUMP REPAIR/ DESTRUCTION '`/.,f <br /> Other / // UMP REPLACEMENTS /? <br /> DISTANCE TO NEAREST. SEPTIC TANK" <br /> SEWER LINESPTT PRIVY ; <br /> SEWAGE DISPOSAL FIELD CESS OOL/SEEPAGE PIT <br /> PROPERTY fINE •- PRIVATE.DOME$TTC.WELL PUBLIC DOMESTIC WELL C1 <br /> INTENDED USE TYPE. OF WELL <br /> Industrial ;, CONSTRUCTION SPECIFICATIONS <br /> Cable Tool �` l3ia; 'of Well Excavation <br /> Domestic/private Drille-d <br /> Domestic/publici�: of Well. Casing <br /> Irrigation Driven t j Gauge of Casing . <br /> Gravel Pack Depth of Grout Seal - G <br /> Cathodic Protection ~ Rotary_ h: .. �T e ;nf Grout <br /> Disposal - ;Other Othee�. Information i <br /> Geophysical _ <br /> Surface Seal Installed 'B : <br />.PUMP INSTALLATION: Contractor '" <br /> Type of Pump < • =. _. <br /> H.P. <br /> PUMP REPLACEMENT: StteWort� Done <br /> PUI`ZP '.REPAIR: State Work Doris <br /> DES•TRUCTTON 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 trict <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my ware on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before putting..the..we11 in use... <br /> The Lnformation is true to the best.of-.my..knowledge and belief. I WILL CALL 'FOR A GROUT INSPE&fON <br />'RIOR TO GROUTING AND�AF�NALINSPE ION. <br />'SIGNED I <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I FOR DMT T USE ONLY <br /> 3.'PLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE <br /> P OUT INSPEC <br /> NSPECTION BY <br /> DATE � P E III FINAL YNSPECTTON � <br /> E H 1426 Rev. 1-74 <br />