Laserfiche WebLink
�AN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �� <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ �//G -- _ CESUS TRACT <br /> 11 <br /> Owner's Name Phone — Z <br /> Address �i�i Psi C City -- <br /> P f "- <br /> r License # Phone <br /> Contractor's Name <br /> _ of d a�U e,06�l c <br /> TYPE OF WORK (Check) ; NEW WELL '/-7 DEEPEN ,/ / RECONDITION I� DES <br /> .TRUCTION � <br /> PUMP INSTALLATION I / . PUMP REPAIR PUMP REPLACEMENT /� l <br /> OChet / / ` <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Dia of Well Excavation <br /> Industrial Cable Tool � <br /> Domestic/private. Drilled Dia. of Well Casing � <br /> Domestic/Public Driven _ Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary ' Type of Grout <br /> Other Information <br /> Disposal Other <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approxi to Depth <br /> F De cribe 11#terial and ProceO ureF 4n <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW <br /> FIM' REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE / <br /> ADDITIONAL -COMMENTS: <br /> PHASE ii GROUT INSPECTIONPHA II/FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 910 - <br /> E E R 1426 Rev. 1-74 -- <br />