Laserfiche WebLink
_�--- SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> FOR'foOFFTCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: :(209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> A <br /> THIS PERMIT'EXPIRES 1 YEAR FROM DATE ISSUED Date Issued c� <br /> ` <br /> (complete In Triplicate), <br />� P <br /> Application is hereby made to therSan Joaquin n Local—Health—District for .aermit to-construct . <br /> ct . <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 Distirict. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner'8 Nairne � <br /> ��a of a r• G Phone <br /> Address � ��y ," � ® �a/.c� ;, _. .. <br /> City <br /> Contractor's Name License # .1 c3 &U—'Phone <br /> I` <br /> TYPE OF WORK � - a 1 <br /> (Check).� NEW WELL '/? DEEPEN /7 RECONDITION /7 DESTRUCTION /-7 <br /> r PUMP INSTALLATION /-7. PUMP REPAIR /W PUMP REPLACEMENT /7 <br /> 0 then / <br /> DISTANCE TO -NEAREST: SEPTIC TANK SEWER LINES <br /> PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT• OTHER <br /> PROPERTY LINE _ PRIVATE DOMESTIC WELL` ' F` PUBLIC DOMESTIC WELL <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 F Gauge of Casing <br /> - , fes Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout +"a <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump «� H.P. a - <br /> PUMP REPLACEMENT: %/ State Work Dane ' <br /> PUMP REPAIR: IZ7 State Work Done 2 a 01-04 •. <br /> ES-TRUCTION OF WELL: Well Diameter <br /> 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 nd belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO TING AND A FIN N <br /> SIGNED 1 <br /> TITLE 3 <br /> (DRAW-PLOT PLAN ON UVERSE SIDE <br /> 01 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . DATE 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ; PHA III/FXNAL INSPECTIO <br /> INSPECTION' BY DATE INSPECTION- BY DATE <br /> E H 1426Rev. 1-74 1-74 2M <br /> --- <br />