Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: c00 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ_61j,; ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> AX W <br /> JOB ADDRESS/LOCATION 1- £ -:lo &,,p ? � �, r CENSUS TRACT OZS-!�D 3L <br /> Owner's Name( t Phone 7 <br /> Address City f <br /> Contractor's Name <br /> License #/G z 323 Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN /_% RECONDITION /-T DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR '/—/ PUMP REPLACEMENT j <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <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 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP -INSTALLATION-:- Contractor �iGcyY <br /> Type of Pump H.P. <br /> 1 <br /> PUMP REPLACEMENT: . State Work Done <br /> PUMP .REPAIR: / / 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 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 well 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 GWTIgO AND NAL IN8PECTIO. f <br /> SIGNED TITLE € <br /> 'jgW`M T' PLAN 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> A ! <br /> APPLLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE Ili ,FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -,2 7 <br /> E H 1426 Rev. '1-74 <br /> 3/76 2M <br />