Laserfiche WebLink
- _ - -_ . <br /> SAN:•"JOAQUIN 'LOCAL HEALTH DISTRICT <br /> FOR+OFFICE USE: ' 1601 E. Hazel'tori-'Ave. , -Stockton, Calif. <br /> Telephone:'; 209) 466-6781 <br /> APPLICATIOf FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � ' <br /> ,THIS PERMIT EXPIRES 1,.:YEAR < ROl .-DATE ISSUED Dkate" issued `lam <br /> (Complete -In Triplicate)" <br /> Application is hereby made to the Sang .Joaquin 1oca-1 zHeal-th. �]istrict•_ffor .a-Permit to construct <br /> and/or install the work .herein described, This '.applicati-an..is: made yin=- ompltaince.,With San Joaquin <br /> County Ordinance No. 1862 and the-,.Rules.,and Regulations::of .the>,:--saw Joaqu� cat:Health District. <br /> E ` <br /> JOB.ADnREss/iACATION .., cvsus TRACT <br /> Owner's Name <br /> 10 <br /> Phone <br /> Address _ <br /> . `city: <br /> Cohtractor'.s Name. License #'C( phone <br /> TYPE OF WORK (Check): NEW WELL /7' DEEPEN : • RECONDITION -/� -DESTRUCTION �~ <br /> / • , <br /> PUMP INSTALLATION / PUMP REPAIR /%, ; .PUMP REPLACEMENT %Jrt <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK C 0SEWER LINES PIT- PRIVY <br /> SEWAGE DISPOSAL FIELD, CESSP/SEEPAGE PIT OTHER <br /> PROPERTY-LINE -' PRIVATE DOMESTIC WELL' "PUBLIC'DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRtTCTION SPECIFICATIONS- A3 <br /> ,Industrial Cable Tool Dia. of Well Excavation IZI <br /> v Domestic/private Drilled- Dia: of- Well, Casit;g <br /> Domestic/public 'Driven Gauge of Casing . _ <br /> - _ Irrigation Gravel Pack Depth of Graut� Seal i <br /> ` Cathodic PrRotary. ^;� y Type .of, Grout <br /> Disposal Other Other Information <br /> Geophysical c a <br /> Surface Seal Installed,B : <br /> PUMP INSTALLATIONt Contractor <br /> Type of 'Pump H.P. <br /> PUMP REPLACEMENT: /. / State Work Done <br /> SUMP REPAIR: - -/� State- :Work-Donee ') - <br /> ESTRUCTION OF WELL: Wel ' <br /> 1 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 'furoish. the San Joaquin- Local Health District a <br /> WELL DRILLERS REPORT of the well and notify :them before putting the- yell in-use.. The above <br /> information is true to the best:- of, myknowledge and belief, 'I :WILT, CALL FOR -A GROUT XNSPECTIONr <br /> PRIOR TO ROUTING ANDA NAL I ECTI N.�_ = <br /> SIGNED � �' ' TITLE `� <br /> DRA LOT ON REQ SE 'SIDE - .. - <br /> . ... OR DEPARTMENT US . .ONLY f <br /> X P A ION ACCEPTED BY r <br /> DATE k �)-s 2 <br /> ADDITIONAL COMMENTS: di <br /> 's PHASE 11 GROUT INSPECTION , I�FHASE III FINAL INSPECTION. . ; <br /> INSPECTION BY DATE -16 INSPECTION BY g 1_-,y DATE <br /> i E H 1426 Rev. 1-74 ,. ..._ <br />