Laserfiche WebLink
SA , J09jUIN LOCAL HEALTH DISTRICT <br /> FOg+OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �5r <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 applicatio:i is made in compliance with San Joaquin <br /> County Ordinance No. 1862 acid the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION _5'51_x-1ae ORO CENSUS TRACT <br /> Owner's Name /,/ L-fIX./_ Phone9 f�� J <br /> Address ' City s jvc A-7v <br /> Contractor's Name License # Phohe" <br /> TYPE OF WORK (Check): NEW WELL-17 DEEPEN 17 RECONDITION DESTRUC <br /> PUMP INSTALLATION / / PUMP REAIR %/ UMC' REPLAC %f <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r,'y <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL- r <br /> INTENDED ;USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing M <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protetfion Rotary Type of Grout i <br /> Disposal Other4 _ Other Information ` <br /> Geophysical ` Surface Seal Installed.By.• „~.. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / V State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> ESSRUCTION OF WELL: Well Diameter if Approximate Depth /® <br /> • Describe Ma:,te;.ial and Procedure <br /> I hereby agree to comply with all lawn 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 h new well, I will furnish the San Joaquin-local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe. well-1n use.. The above <br /> information is true to the best of my knowledA; and belief. I WILL CALL -FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE} _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY (,i/ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I SPECT N PHAU IlI INAL SPECTION <br /> INSPECTION BY DATE INSPECTION BY,,,f,2 DATE ~7 <br /> E H 1426 Rev. 1-74 1-74 2M <br /> r <br />