Laserfiche WebLink
SAN JOAQUIN LOCAL. HEALTH DISTRICT ( � <br /> FOR OFFICE USE: <br /> 1601 E. Hazelton Ave. , ;Stockton, Calif. SCANNED 2' / <br /> * , P Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby 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 //C11)Z CENSUS TRACT <br /> Owner's Name ������ �,.., ` _ • <br /> c� Phone — 7" <br /> //o <br /> Address C' <br /> .y City g�/� G <br /> Contractor's Name License # p Phoney T� f�11 <br /> - <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION /, PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FJELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE/..ZPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS G <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: 1l le C. 1< T <br /> PUMP INSTALLATION: Contractor e? � <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: J / 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 a well and notify them before putting the .well in use. The above <br /> information is true t h� best of my kno edge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO INSPE IO <br /> SIGNED , TITLE ` <br /> (DRAW PLOT AN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS t INSPECTION PHA I A64W, INSPECTION <br /> INSPECTION BY DATE/ 7� INSPECTION B DATEa)�} <br /> E H 1426 Rev. 1-74 2M <br />