Laserfiche WebLink
i6p SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORfOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WEj.L CONSTRUCTION OR PUMP PERMIT Permit No. ,$= <br /> 7s. s-.4�gJ� <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 /> 1 <br /> JOB ADDRESS/LOCATION /�,/ ,�- j �, 3 CENSUS TRACT <br /> Owner's Name � P �E ;n��/ Phone <br /> Address City <br /> Contractor's Name sY)/ License # <br /> Phone . t1' <br /> TYPE OF WORK (Check): NEW WELLDEEPEN -/'7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION L -�77U P REPAIR /-7—PUMP REPLACmz9T 17 <br /> Other / 7 <br /> DISTANCE tO NEAREST: SEPTIC TANK frau-�x- SEWER LINES f,-o PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE STIC WELL PUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool ' Dia. of Well Excavation f� � <br /> -r' omestic/private Drilled Dia. of Well Casing 6 "•� c� <br /> Domestic/public Driven Gauge of Casing 'A1 <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 BX: �i �' s �= •' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: _U. :State Work`Done <br /> PUMP :REPAIR: L State Work`Dona _.,.,. <br /> ES-TRUCTION OF WELL: Well Diameter v 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 rpgulsting well construction. Within FIFTEEN DAY <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED ".7-'. 0 _ ' TITLE J:r:= <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIX[FXNAL INSPECTIO <br /> INSPECTION BYDAT$ �� INSPECTION BY DATE <br /> 1 E H 3.426 Rev. 1-74 1-74 2M <br />