Laserfiche WebLink
I� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I; Telephone: . (209) '466-6781 ���+ <br /> j APPLICATION FOR'WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I� . . p! <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date Issued `3 '7U .i <br /> (Complete In Triplicate) <br /> Application is hereby made to the .San Joaquin Local Health District for a permit to construct <br /> and/orlinstall the work herein described. This application is made in compliance with� San Joaquin <br /> Countyr.Ordinance No. 1862 and the Rules and -Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner°s Name /p,e/ {� ,tlE Phone <br /> E ! <br /> Address f / ,Q City <br /> ----Phone <br /> Contractors Name <br /> License ��fKo.2�6�SD <br /> TYPE OF WORK- (Check) : NEW WELL_../_/.,.DEEPEN.'// _ CONDITION / � DESTRUCTION <br /> 'PUMP INSTALLATION '/ / PUMP REPAIR /v/� PUMP REPLACEMENT 17 <br /> I' Other / C; <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 µ Cable Tool Dia. of Well Excavation s <br /> IDomestic/private Drilled Dia. of Well Casing n <br /> (Domestic/public Driven Gauge of Casing <br /> ( Irrigation _Gravel Pack Depth of Grout Seal <br /> (Cathodic Protection Rotary Type of Grout <br /> IDisposal Other Other Information-' <br /> IiGeophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ! <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done /O <br /> DES•TRU•CTION.iO.F-W-ELL:,i.,Wel.lq.Diame_ter-- Approximate-Depth, <br /> j Describe Material and Procedure <br /> I 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 GROUTIAND A' F AL I PECTION. <br /> SIGNED �( TITLE <br /> ,: , D -pZ T PLAN 'ON RE FRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> I APPLICATION ACCEPTED BY;, ' — DATE <br /> ADDITIONAL COMMENTS: - <br /> i PHASE II GROUT .INSPECTION PHASE I/ AL INSPECTION <br /> PECTION BY -'� DATE ., ' . r ,. . =: INSPECTION BY DTE <br /> INS <br /> 3/76 2M <br /> E!H 1426 Rev. 1--74 <br />