Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> F Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, a <br /> THxS,-PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In .Triplicate) , <br /> Application is hereby made to the Sari 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 anal the .Rules and Regulations ofthe: San Joaquin Local Health District. <br /> ­:CCK <br /> JOB ADDRESS/LOCATION ,. v .Q� 9� -- / <br /> r� ✓►°' ���� '• CENSUS TRACT .0'7/- /40­0) <br /> Owners Name .I 4 ✓r Phone <br /> Address AlD , y City <br /> Contractor's Name. /, . . <br /> f , . <br /> License # y y Phone 7G,,,�5 <br /> x <br /> i <br /> TYPE OF WORK .(Check): NEW WELL /7 DEEPENL/7RECONDITION'/77 <br /> `DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR Z27 PUMP REPLACEMENT <br /> Other/./ <br /> DISTANCE TO NEAREST: SEPTIC ITANK SEWER LINES . PIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT OTHER �� ;� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELT; { <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. -of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public r Driven Gau a of-Casing. - <br /> • <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection ' j Rotary Type of Grout <br /> Disposal I Other <br /> �. Other Information.- <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> cc. <br /> Type of Pump,.- H.P. <br /> �' - <br /> PUMP REPLACEMENT: w Y / I State Work Done <br /> PUMP,;.REPAIR.- <br /> /Y7 State Work Dane24pl&i Aft + <br /> & ' UCTION OF WELL: Well Diameter <br /> Describe Materialand Procedure Approximate Depth i <br /> 1 , <br /> I hereby agree to comply withlall Laws and regulations of the San Joaquin Local Health District E <br /> and the State of California pertaining to or regulating well 'construction. <br /> AYS <br /> _after completion of. my work on a new well, I will furnish the San Joaquin Local hHealth Din istrict a <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..weli in use.. The above <br /> information is true to the best.of: my.knowled e-ait5belief. I `WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INS N. <br /> SIGNED ITLE F <br /> � . D P 0 PLAN ON RE RSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE .ONLY <br /> � . <br /> APPLICATION ACCEPTED BY <br />.ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHAII FINAL INSPECTIO <br /> INSPECTION BY - DATE INSPECTION BY <br /> DST <br /> DATE (J <br /> a <br /> E H 1426 Rev. 1-74 <br /> 1-71. 9br <br />