Laserfiche WebLink
' C <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> 'OFFICE USE: ' 16C Hazelton- Ave.:} Stockton Cal <br /> i Telephone: (209)! 466-6781 <br /> .6r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9�3� <br /> THIS PERMIT EXPIRES l.-YEAR FROM DATE ISSUED Date 'Issued /- _7 <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 Joaquli <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Digttict. <br /> 1 JOB ADDRESS/LOCATION a CENSUS TRACT <br /> Owner's Name d -C J L r 11' ._ Phone <br /> Address 2p City ' <br /> Contractor's Name License # 0903 .Phone a <br /> TYPE OF WORK (Check) NEW WELL '/—/ DEEPEN /7 RECONDITION /_7 DESTRUCTION /j� <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /'7. <br /> Other <br />' DISTANCE"TO NEAREST: SEPTIC TANK . SEWER LINES PIT PRIVY <br /> i SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C <br /> f PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION. SPEC IFICATIONS L, <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 Graver-Pack Depth of Grout Sea-1--- <br /> Cathodic <br /> ea-1--Cathodic Protection Rotary Type of Grout <br /> Disposal. Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION; Contractor 14 i , <br /> Type of Pump . N.P. Q <br /> PUMP REPLACEMENT: . j5F State Work Done�© <br /> PUMP '.REPAIR: /% State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure -'T <br /> I hereby agree to comply with all laws. and regulations of the San Joaquin Local Health bistiict <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 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 TOJGR TING'AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i€ <br /> FOP, DEPAPXMENT USE ONLY <br /> PHASE i APPLICATION ACCEPTED BY ryt•.Y. DATE IE-17ADDITIONAL COMMENTS: <br /> '`i PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DTE. % <br /> E H 1426 Rev. 1-74 <br />