Laserfiche WebLink
i, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> !E <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 79_ rwp <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED date Issued �7-%0'7�' <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. is application is made in compliance with San Joaquin <br /> County'Ordinance No. 1862 and the Wee .Regulations of a San Joaquin Local Health District. <br /> JOB ADDRESSWN . D <br /> / f CENSUS TRACT <br /> IryOwner's Name Phon <br /> op <br /> AddressCi4�qhot <br /> Contractor's Name License , <br /> p <br /> d <br /> TYPE OF WORK (Check): NEW WELL.-/-7 DEEPEN ,/-7 RECONDITION /'? DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR :/W7PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY o4 <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER N <br /> PROPERTY LINE - PRIVATE DO ESTIC WELL' PUBLIC DOMESTIC WELL W <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 7 <br /> Irrigation Gravel Pack Depth of Grout Seal 1 <br /> Cathodic Protection Rotary Type of Grout 4 <br /> Disposal Other Other Information <br /> Geophysical ` Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: • /.� / State Work Done <br /> PUMP '.REPAIR: V State Work. Don <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - Describe Material and Procedure <br /> E <br /> I hereby agree to comply,1with 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..we11- in.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 TITLE F4 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY - - -- - -� <br /> PRASE I II <br /> APPLICATION--.ACCEPTEDBY �3 DATE ! <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION MASE II FINAL INSPECTION <br /> INSPECTION BY E INSPECTION BY DATEN11D./- 7s" <br />`qti �E H'1426 ' ` c <br /> Rev. 1-74 � _ �"- h/75 2M:., j <br />