Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOt OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;ti- )o <br /> THIS PERMIT EXPIRES 1 'YEAR. FROM DATE ISSUED Date Issued &-.L4 _7� <br /> VV (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 - (��P �� GijCENSUS TRACT <br /> Owner's Name Phone <br /> Address /ls- ,e �y. 9 1 City <br /> Contractor's Name License #A40& Phone <br /> TYPE OF WORK (Check): NEW WELL 1-7 DEEPEN '/—j RECONDITION lT DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT A <br /> Other f-1 <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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal t� <br /> Cathodic Protection Rotary Type of Grout (� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work <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 DA <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distric <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 Cub FOR A GROUT INSPECTION <br /> PRIOR TO G UTING A FINAL INSPECTION. ✓ <br /> SIGNED TITLE <br /> D W PEA 'ON REVERSE SIDE h <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I ROUT INSPECTION PHASE,,,1I)r/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> E H 1426 Rev. 1-74 ' <br /> 3/76 2M <br />