Laserfiche WebLink
9 y CAN JOAQUIN LOCAL HEALTH. DISTRICT C <br /> FOR OFFICE USE: j,,-` 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED Date Issued y=z -V6 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct f <br /> and/or install the work herein described. This application is made in compliance with San .;{oaquin � <br /> County Ordinance No. 1862 and the Rules and Regulations of the San J aquin Local Health Distl'ict. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> ' rLyeyJ .r' / yu�C9 v� Phone -37 <br /> Owner's Name <br /> r � �I 1 <br /> Address 44) "--'tel City <br /> Contractor's ,Name �-�� / UL License Phone4 "1d9� <br /> TYPE OF WORK (Check) : NEW JWELL '/ / DEEPEN /_/ RECONDITION / / k DESTRUCTION /77 -LLQ <br /> PUMP INSTALLATION/ I PUMP REPAIR/ / PUMP REPLACEMENT Z <br /> _r <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 <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 Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal __ 4 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information-', <br /> Geophysical Surface Seal Installed By: <br /> 4 <br /> PUMP INSTALLATION: Contractor <br /> ti s <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />-PUMP-�REPA1-R-r / / 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 Joaglain Local Health District t <br /> and the State of California pertaining to or regulating well'constructLon. 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 we11 in use. The above <br /> information is true to the best of- my knowledge and belief. I WILL CALI:. FOR A GROUT INSPECTION 4 <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE _filo <br /> PL T PLAN `ON RE FRSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY �• <br /> ADDITIONAL COMMENTS: k <br /> PHASE II G T S CTION PHASE I /F'I INSPECTIO i <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 .Rev. 1-74 / f <br />