Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT } <br /> FOE OFFICE USEr 1601 E. Hazelton Ave. , Stockton, Calif, - l <br /> Telephone : (209) 466--6781 z <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued --�5_4 7 <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 CENSUS TRACT <br /> Owner's Name sAj Phone LIZ a.7 q� <br /> Address City <br /> �i <br /> Contractor's Name ` �%, � �j ��� Licen �t(c Phone �f� 7 ' <br /> X <br /> TYPE OF WORK (Check) ; NEW WELL/�EEPEN / / RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /_ <br /> 4 Other / / <br />( DISTANCE TO NEAREST: SEPTIC TANK�I ® 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 CaUDF— o 1 Dia, of Well Excavation ?' <br /> -- Domestic/private Drilled=:y; Dia, of Well Casing <br /> Domestic/public .,Driven 3? Gauge of Casing <br /> Irrigation -'Gravely Pack Depth of Grout Seal gj <br /> Cathodic Protection Rotary Type of Grout l r f <br /> Disposal Other . Other Information <br /> Geophysical t. V Surfa�ce�Se-al Lns�talled By: <br /> �y , <br /> PUMP INSTALLATION:l.� Contractor <br /> Type of Pump H.P. `Z <br />+PUMP REPLACEMENT: / / State Work Done <br />'PUMP .REPAIR: / / State Work Done <br />-DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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 lZeal Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well incluse.. The above <br /> information is true to the best of my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT( G ANPA FINAL IWcPECTION. <br /> ''SIGNED TITLE (C') <br /> (DRAW PLOT PLAN ON REVERSE SIDE)' ' j <br /> FOR D PARTMENT USE ONLY <br />,PHASE I <br /> APPLICATION ACCEPTED BY Cir- DATE 2 9 <br /> 1ADDITIONAL COMMENTS: <br /> PHASE. II GROUT INSPECTION r PHASE II /FINAL INSPECTION <br /> INSPECTION BYDATE b INSPECTION BY DATE u2 -16 7 <br /> i E H 1426 Rev. '1-74 / ' <br />