Laserfiche WebLink
E SAN JOAQUTN LOCAL HEALTH DISTRICT <br /> FOR, OFFICE USE: 1601 E. Hazelton :LAve. , Stockton, Calif. <br /> Telephone : (209) -466-6781 <br /> f-71-17 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7--//d P <br /> s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued I` <br /> !I (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the workherein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 186f and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION77L/(/ CENSUS TRACT <br /> Owners Name Phone <br /> Address City <br /> Contractor's Name ,. License � Phone <br /> IM <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / { PUMP REPLACEMENT ' /_/ <br /> Other / <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PTT PRIVY i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE W PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE �� TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ( Cable. Tool Dia. of Well. Excavation <br /> Domestic/privatei� Drilled Dia. of Well Casing ni <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. 1 <br /> 5 <br /> PUMP REPLACEMENT: /i / State Work Done <br /> I� <br /> PUMP .REPAIR: /;� / State Work Done <br /> t4r Of <br /> ESTRUCTION OF WE Well DiameterApproximate Dept , <br /> --- -- <br /> JQ{/ ,0)0& / lescribe 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 .mywork on a new well, I will furnish the Sart, Joaquin Local Health District a <br /> WELL DRILLERS REPORT ofl�the well and notify them before puttingthe well in use.. . The above <br /> information is true to the best of my knowledge and belief. T WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FIN INSPECTION. <br /> SIGNED TITLES <br /> M (DRAW PLOT PLAN ON REVERSE SIDE) <br /> �� FO ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B �M DATE " <br /> ADDITIONAL COMMENTS: 4. i <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY IM DATE INSPECTION BYDATE -�1 <br /> i , <br /> 6/77 _ 2m <br /> E H 1426 Rev_ . 1-7411 __- - <br />