Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton AVe. , Stockton, Calif. <br /> PPU <br /> Telephone: (209) 466-6781 ry <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR� FROM DATE ISSUED, Date Issued _/,,I-/ <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health 'District. <br /> ° CENSUS TRACT , . <br /> JOB ADDRESS/LOCATION" ! � -{ �� //r r, - <br /> Owner's Name b Mnnc tiPhone [n <br /> '4f a <br /> City 1r7� f <br /> Address <br /> �7 i <br /> License Phone /. 4fS>_�PZ5 I <br /> Contractor s Name o S - _-� <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN '/ / RECONDITION / / DESTRUCTION /� <br /> PUMP. INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1r PIT PRIVY <br /> SEWAGE DISPOSAL-FIELD /_!M CESSPOOL/SEEPAGE PIT , OTHER <br /> PROPERTY LINE -f PRIVATE DOMESTIC WELL 2ZZ� 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 f [r <br /> — Domestic/public Driven Gauge of Casing O <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> { <br /> Cathodic Protection Rotary Type of Grout emPsf/T`' <br /> Disposal Other Other Information ._ <br /> Geophysical Surface Seal Installed By IZ a s'3 <br /> PUMP INSTALLATION: Contractor • <br /> Type o{]`f Pump <br />` PUMP REPLACEMENT: /` / S tate Work Done <br /> 1 3 <br /> PUMP .REPAIR: /, / State Work -Done- <br /> DESTRUCTION <br /> Done <br />' DESApproximate TRUCTION OF WELL: Well Diameter PP 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 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 ROUTINQ AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SfbE) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> YI APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS <br /> M P S OUT__INSPECT,IP. E. I/_ --NAL-Z-NS.P.ECTI N�. � <br /> INSPECTION BY ��. DATE INSPECTION BY DATE <br /> 2M <br /> E H 1426 Rev. . -74 <br />