Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF,OFF,CE USE: 1601 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 Date Issued <br /> (Complete In Triplicate) <br /> Applicat=ion is hereby made to the San Joaquin Local Health District for a permit to construct s <br /> and/or install the work.,herein described. This application is made in -compliance with San Joequin:, <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 0,:2, 4!2Ct CENSUS TRACT ' ' <br /> Owner's Name (S L Phone <br /> Address �,s ee City _ <br /> Contractor's Name A. License J1.2 0 ! Phone7/f <br /> TYPE OF WORK (Check) : NEW WELL% DEEPEN/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION I / PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other / / — <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 i. ^^ Cable Tool Dia. of Well Excavation At <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing �� <br /> Irrigation - --Gravel- Pack-- -Depth of Grout Seal f N <br /> Cathodic Protection Rotary Type of Grout P <br /> Disposal w.Othex Other Information <br /> Geophysical Surf ace Seal Installed By: r <br /> PUMP INSTALLATION: Contractor S <br /> _ "Type.-of-Pump­ t, H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> iPUMP -.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: ;Well Diameter Approximate Depth <br /> `Describe Material and Procedure <br /> j 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,t:rue to the best of my knowledge. and belief. I WILL CALL FOR A GROUT '.TNSPECTION <br /> PRIOR TO GROUTING AND A FI INSPECTIO .� <br /> SIGNED TITLE y'' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ON*. / <br /> PHASE I <br /> APPLICA ION ACCEPTED BY E // <br /> ADDITIONAL COMMENTS: <br /> '� a zfiy/'� <br /> PHASE II GROUT INSPECTION IN EC ON <br /> INSPECTION BY DATE -f ""] 7 INSPECTION BDATE S <br /> 1f�7 2M <br /> E H 1426 Rev. 1-74 __ <br />