Laserfiche WebLink
A-1 <br /> b rlL SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE.: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ("09) 4(6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT o. ,7%T-jj& <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ! (Complete In Triplicate) <br /> Application is liereby 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 /> Count Ordinance No. 1862 and the Rule and Re ul tions of the San Joaquin Local Health DistTict- <br /> y /.� �drr� o� :' f <br /> JOB ADDRESS/LOCATION <br /> ENSUS TRACT <br /> Owuer's Name _ 7L T � Phone <br /> Address d- City f <br /> ',License #,P 1 - phone <br /> „g Contractors Name --�—i <br /> S <br /> vy <br /> x TYPE OF WORK (Check): 14EW WELL DEEPEN /-7 RECONDITIO /? DESTRUCTION-� <br /> w . PUMP INS LATION I I PUMP REPAIR /�] PUMP REPLACEMENT /7 a <br /> Other <br /> 'ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES IT PRIVY .' <br /> SEWAGE DISPOSAL FIELD CESS OOL/SEEPAGE PI OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> p INTENDED USE TYPE OF WA L CONSTRUCTION SPECIFICATIONS <br /> Industrial le Tool Die. of Well Excavation <br /> =Domestic/Private Drilled Dia. of Well Casing t7w 'r <br /> Domestic/public Driven Gauge of Casing4 21!f E <br /> _w6�rrigation Gravel Pack Deprh of Grout Seal � . <br /> Cathodic Protection Rotary :"ype of Grout <br /> f� Disposal Other Other Information _ F <br /> Geophysical Surface Seal Installed BY: a <br /> P.^ <br /> PUMP INSTALLATION: Contractor <br /> Type of F�mp <br /> H.P. <br /> PUMP REPLACEMENT: I I State Work Done <br /> PUMP --REPAIR.- / / State Work Done <br /> DES-TRUCTION OF WELL: Well. Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> .j <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Districts <br /> and the State of California pertaining to or regulating well'construction. Within FIFTEEN DAIS' <br /> after completion of my work on a new well, I will furnist. the San Joaquin Local Health District, & <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above 'k <br /> information is ue to the br.st ;- my knowledge and belief. I WILL FOR A GROUT INSPECTION€` <br /> PRIOR TQ CROU N� AND A-F'INAi. PEQTTON.% II <br /> SIGNED TITLE d <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> F DEPARTMENT USE ONLY ' <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATF. i <br /> COMMENTS;ADDITIONAL CO `° <br /> �. PHASE 11 GROUT INSPECTION PHASE II FINAL INSFECTiON �b <br /> 'r INSPrCTTON BY DATE INSPECTION SY _ DATE 4 <br /> a� r: <br /> if 1426Rev. 1-74 1/7/ 2!! <br /> F <br />