Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR'OFFICE USE: 1b01 E. Hazelton Ave. , Stockton Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued �� <br /> (Complete In 'Triplicate) <br /> App -ication 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 Ru R ulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOC % <br /> / CENSUS <br /> TRACT <br /> Owner's Name <br /> Address Phon� <br /> 77 <br /> A 1 <br /> City <br /> Contractor's Name j <br /> License 44 Phone J11649 <br /> TYPE OF WORK (Check) : NEW WELL — <br /> DEEPEN -/ <br /> /DEEPEN /�/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / PUMP REPAIR PUMPREPLACEMENT /7 <br /> Other / / _ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY. LINE » PRIVATE DOMESTIC WELL PUBLIC OTHER <br /> ITENDED USE TYPE OF WELL DOMESTIC WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing �a <br /> Irrigation <br /> Domestic/public f Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout A <br /> Disposal I Other Other Information lir <br /> Geophysical Surface Seal Installed By: <br /> PULP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT State Work Done <br /> PUMP -REPAIR: S�ork Donxeo-� <br />]ES-TRUCTION OF WELL: Wel]. Diameter <br /> Describe` Material and Procedure Approximate Depth <br /> i -� <br /> C hereby agree to comply with all laws and regulations of the :an Joaquin Local Health District <br /> and the State'of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> ifter completion of my work on 'a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before,putting the -well in use. The above <br /> Lnformation is true to the best af. my knowledge and belief.. <br /> RIOR TO GROUTING AND A FINAL INSPECTION. I WILL CALL FOR A GROUT INSPECTION. <br /> iIGNED <br /> TITLE <br /> RI S IDE 3,.. ,: 4 <br />'HASE I FOR DEPARTMENT USE ONLY j <br />,PPLICATION ACCEPTED B <br /> DDITIONAL COMMENTS: eDATE <br /> PHASE lCI T PECTIC PHASE III/FINAL ON INSPECTI <br /> NSPECTION BY DATE INSPECTION BY z M <br /> DATE <br /> E' H 1426 Rev. 1-74 <br /> __ 3/76 2x <br />