Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT - -- -- <br /> OR 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 _z_ _76 <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 0110 Cf CENSUS TRACT <br /> a o <br /> Owner°s Name - Phone — -1 <br /> Address , •/ City <br /> Contractora Name c '"t � -� v =%rr% License fi�V6p Phone <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /_J 'UMP PLAC NT <br /> ,. Other /7 r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELT, ' PUBLIC DOMESTIC WELL �. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS b <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �� <br /> t Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 4 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: \I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. T' <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMPREPAIR: /_7 State Work Done _ Q <br /> ES;TRUCTION 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 FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING INAL INS CTION. <br /> SIGNED " .. TITLE ��.. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE --r <br /> r E H 1426 Rev. 1-74 1-74 2M <br />