Laserfiche WebLink
vSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOErOFFICE 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 EXPIRE$ 1 <br /> YEAR FROM DATE ISSUED Date Issued-za-a. �d <br /> (complete <br /> Application is'hereby made to the± SanJv uinLocal. Realth District foraei <br /> f <br /> and/or- install -the-work herein described. This application is made in compliancetwithnstruct San Joaquin <br /> County Ordinance No. 1862 a:ad the Rules and Regulations of the San-Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner s Name <br /> Phone <br /> Address ` -a IC, - <br /> Cit t <br /> City .G <br /> Contractor's Name , License # �0 Q - <br /> � � i Phone - <br /> TYPE OF. WORK '(Check): NEW WELL DEEPEN 1_7 RECONDITION /__7 DESTRUCTION f7 - <br /> PUMP INSTALLATION / / PUMP REPAIR /.f/_PUMP REPLACEMENT <br /> 0their>7/J <br /> DISTANCE TO NEAREST: SEPTICjTANK SEWER LINES PIT PRIVY <br /> SEWAGEtDISPOSAL FIELD (CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL M <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS -1b <br /> s Z� ,. <br /> Industrial 1 Cable Tool Dia. of Well Excation <br /> Df� <br /> Domestic/private � -� Drilled av <br /> � Dia. of Well Casing y) j <br /> Domestic/public Driven <br /> ,Irrigation i Gravel Pack gauge of Casing <br /> Depth of Grout Seal <br /> Cathodiic T.rotectionf Rotary Type of Grout <br /> Disposal Other � Other Information � <br /> Geophysical 'Surface Seal Installed By: <br /> PUMP INSTALLATION. ? <br /> ` Contractor <br /> Type of Pump •'i _ �. •rs H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP !-REPAIR:- <br /> _ / / "`State-Work"Donees <br /> E&TRUCTION 0� F WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply jall laws and regulations of the San Joaquin Health District <br /> and the State of California pertaining to or regulating well 'constructioa. 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 IGROUT INSPECTI N <br /> PRIOR TO 'GROUTING AND A FINAb INSPECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE f <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I �- <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION - FI AL INSPECTI N _. <br /> INSPECTION BY DATE INSPECTION BY J , DATE <br /> 9l�' fk <br /> S.^. -. <br /> E R 1426 Rev. 1-74 h <br /> 7-7 L Air <br />