Laserfiche WebLink
_ SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> It Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 777yy" <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued X12 <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 /> li County Ordinance No. 1862 and the ales and Regulations of the San Joaquin Local Health District. <br /> w n <br /> JOB ADDRESS/LOCATION � • D1L U 1 ENSUS TRACT <br /> Owner's Name . f Phone 3(, fF'^o_f Q e <br /> Address Cityfa-zed! <br /> _" <br /> Contractor's Name License Phone (A <br /> Y _ A <br /> TYPE OF WORK (Check) : NEW WELL -/? DEEPEN/ / RECONDITION /� DESTRUCTION /� <br /> PUMP INSTALLATION _4?' PUMP REPAIR f. / PUMP REPLACEMENT /? <br /> Other /_7 <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 Cable Tool Dia. of Well Excavation IT\ <br /> Domestic/private Drilled Dia. of Well Casing \6 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ,; <br /> Disposal1 Other Other Information ' <br /> Geopt ysical . _' - , � _ Surface--Seal. Installed By: _ <br /> I <br />' 'PUMP. INSTALLATION: Contractor <br /> i Type of Pump H.P. /0 <br /> PUMP REPLACEMENT: . / / State Work Done <br /> I 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 best of my.-knowledge and belief.- I WILL CALL FOR A GROUT INSPECTION• <br /> PRIOR TO GROU G OD A FI NSPECT <br /> SIGNED TITLE <br /> f W.PWT PLAN 'ON UWkSE SIDE f:. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL iCOMMTS: <br /> PHASE II GROUT INSPECTIONPHASE I INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> E 3/76 2M• <br /> E H 1426 Rev. 1-74 <br />