Laserfiche WebLink
i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED-- Date Issued 11" <br /> (Complete In Triplicate) <br /> Application is hereby made Co 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 Rule Regulations of the an Joaquin Local Health District. <br /> JOB ADDRESS/LOC T CENSUS TRACT <br /> f Owner's Name <br /> Phone �7 <br /> Address - I Cit <br /> r License Phon <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION DESTRUCTION /7 <br /> PUMP INSTLATION/ I PtW REPAIR 5 PUMP REPLACEMENT /� <br /> AL <br /> Other; <br /> I E <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 fr Cable Tool Dia. : of Well Excavation <br /> 'j Domestic/private F Drilled. Dia., of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing ( , <br /> Irrigation j. ­rGravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Information <br /> Geophysical t Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type- of Primp H.P. <br /> PUMP REPLACEMENT: / / i State Work Done <br /> Pump�,REPAIR '¢""' "" State Work Don <br /> DES-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 Californiaipertaining 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 thell and notify them before putting the .well in use. The above <br /> information is true to the est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. p ' <br /> SIGNED I TITLE <br /> DRAW PL T PLAN ON REVERSE SIDE) <br /> FOR DEPA3tTMENT USE ONLY <br /> PHASE I / DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPE TION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> R H 1426 Rev. 1--74 .- <br />