Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 Pe <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 79-514 /Q <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 -"- /--14 CENSUS TRACT <br /> Owner's Name c� - Phone <br /> Address City <br /> Contractor's Name < License #—'1 d4'M Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN I / RECONDITION /_/ DESTRUCTION /- _ <br /> PUMP INSTALLATION 1, / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /-7 <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 /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled _Dia, of Well Casing Q <br /> Domestic/public Driven Gauge of Casing <br /> Y Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. Other Other Information <br /> Geophysical Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor Imes <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT j—/ State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 thembest of my knowledge and belief. I WILL C4a FOR A GROUT INSP ION <br /> PRIOR TO G OUTING --FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW POT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION rPHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -2-2,-7&1 <br /> E H 1426 Rev, 1--74 <br /> 3/76 2M <br />