Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT �S <br /> FOk OFFICE U� SE: 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 Issuedo-2 /(!-70V <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 application is made in compliance with San Joaquin <br /> County Ordinance No, 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,W, t3 a/1 - CENSUS TRACT :Z`{�'-(sb <br /> Owner's Name Phone <br /> Address 44F.9 City <br /> Contractor's Name , License Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL X DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> ALL <br /> PUMP INSTATION REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK i�1 SEWER LINES PIT PRIVY �. <br /> SEWAGE DISPOS4 FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINO-+ PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL (A] <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing fp G, _06:�Ajw_j„// <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> DESTRUCTION 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 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 es o&ON—.nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T U NG D A FT AL RVSP <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _..� .�.�. _._ _,. ., ,. DATE ,.2, 41 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEUT <br /> /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE S �� <br /> E H 1426 Rev. 1-74 ' 1177 2M <br />