Laserfiche WebLink
4/1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOKOr"FIC 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 i/9?� <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 Phone C31 2-6 <br /> Address City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN J? RECONDITION %T DESTRUCTION f <br /> PUMP INSTALLATION / / PUMP REPAIR'/? PUMP REPLACEMENT % f <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 U� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation �1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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: , Ll State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Deph <br /> esc be Material Proc duce <br /> .1, e4-., <br /> I hereby agree to comply with all/laws and regulations o e San Joaquin Local Health Dis r ct <br /> and the State of California pertaining to or regulating well '•constructianf. °•.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.° n.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 GROUTING AND A FINAL INSPECTION. <br /> 'SIGNED j, TITLE <br /> DRAW PLN ON REVERSE SIDE <br /> EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE . <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION �BfP <br /> E III FINAL .INSPECTION <br /> INSPECTION BY DATE SPECTTON DATE <br /> E H 1426 Rev. 1-74 r r " <br />