Laserfiche WebLink
f N JOAQUIN LOCAL HEALTH DISTRICT <br /> .`"-"y <br /> FOR OFFICE USE: !/ 16 , E. Hazelton Ave. , Stockton, Cz <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 <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 wade in compliance with San Joaquin <br /> County ".,Ordinance No. 1862 and <br /> �Jthe <br /> `�Rules and Re ulations of tan Joaquin Local Health District. . <br /> JOB ADDRESS/LOCATION � O" ✓ he q Q CENSUS TRA& <br /> AV <br /> Owner's Name ' a/y✓ .Phone//6 A` 7"4 <br /> Address City cgg, - - <br /> Contractor's Nance �a LicenseY,--,/Phone (o <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN /7. RECONDITION /_7 DESTRUCTION /_° <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT ]-7 <br /> Other j_7 <br /> DISTANCE TO NEAREST: ' SEPTIC TANK;&r 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 <br /> /Domestic/private Drilled Dia. of Well Casing <br /> Domestid/public :Driven Gauge of Casing ! Rj <br /> Irrigation :Gravel PackDepth of Grout Seal � <br /> Cathodic. Protection ' .Rotary Type of Grout R, <br /> Disposal' Other Other Information ' [� <br /> k Geophysical Surface Seal Installed py._: <br /> PUMP INSTALLATION: Contractor : <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / 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 6f- California pertaining to or -regulating well''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new Iwell, I will furnish the San Joaquin Local Health District a <br /> f WELL DRILLERS REPORT of the well and notify thein 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 FI Na 15EPEWION. <br /> SIGNED 'TITLE <br /> D W,: PLAN `ON RE 'RSE StbE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DA = <br /> ADDITIONAL COMMENTS: <br /> PHASE iI GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> I INSPECTION BY DAT'E' Its A T '14- INSPECTION BY /r%, . DATE e- J- L: <br /> E H 1426 Rev. 174 - <br /> 3/70 . 2M . <br />