Laserfiche WebLink
l �If-IV <br /> SAN SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOYMOFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-»6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �p�-7-75 <br /> (Complete In. Triplicate) <br /> Applicationlis hereby made to the San Joaquin Local Health District for a permit to Construct <br /> t and/or .install the work herein described. This application is made in compliance with San Joaqui <br /> County Ordinance No. 1862 nd the Rules and Regulations of the Saar Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4 �v J .� CENSUS TRACT <br /> � � <br /> Owner's Name `f�`' � Phone ?a! <br /> Address <br /> City <br /> Contractor's Name License <br /> License, � -!3�honeTYP "'�� <br /> E OF WORK (Check) . NEW WELL -/ 7 DEEPENT7 7 RECONDITION /7 DESTRUCTION f f <br /> PUMP INSTALLATION / / PUMP REPAIR/_7 PUMP REPLACEMENT <br /> I Other E7 <br /> k DISTANCE TO NEAREST: ` SEPTIC TANK SEWER LINES PIT PRIVY <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 (n <br /> ! - Domestic/private DrilledDia. of Well Casing C <br /> Domestic/public Driven Gauge of Casing f� <br /> Irrigation Gravel Pack- Depth of Grout Seal I <br /> Cathodic Protection Rotary Type of Grout <br /> 'Disposal Y Other Other Information ! <br /> Geophysical . . . Surface Seal Installed "By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ' State Work Don <br /> PUMP-=:REPAIR /— - ... . .�., <br /> /`"„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 /> t 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> n.. <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE i FOP, DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED $ DAT <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE G <br /> k <br /> L <br /> E H 1426 _ Rev. 1-74 1./7K 9M <br />