Laserfiche WebLink
01 <br /> <Y r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> N3 - <br /> .FROM DATE 'ISSUED Date Issue <br /> THIS PERMIT EXPIRES 1 YEAR 1978 . . <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 /> JOB ADDRESS/LOCATION L7 r CENSUS' TRACT <br /> Owner's Name Phone <br /> Address " _Lf City <br /> Contractor's Name .Ae License #17 <br /> Phone <br /> TYPE OF WORK (Check: NEW WELL/ / DEEPEN /? RECONDITION f? DESTRUCTION f f <br /> AL <br /> PUMP INSTLATION / J PUMP REPAIR/_7—PUMP REPLACEMENT <br /> Other <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY V <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 x <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 Rota-ky Type of Grout <br /> Disposal Other Other Information ' ' i <br /> Geophysical. Surface Seal Installed 'B :' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. $ <br /> PUMP REPLACEMENT: . State Work Done _ a <br /> PUMP '.REPAIR: <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure � <br /> 1 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 F'I'FTEEN 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 GPQUTING ANDA FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE S <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIF AL INSPECTION e <br /> INSPECTION BY DATE INSPECTION BY DATE V <br /> E H 1426 Rev. 1-74 r r _ L175 2M ' <br />