Laserfiche WebLink
- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOrn .OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <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 Issuect <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 Regulation's of the San -Joaquin Local Health District. <br /> ' JOB ADDRESS/LOCATION '146s r CENSUS TRACT <br /> k . <br /> T <br /> Owner's Name - - Phone ,A/;/V,//-3/ <br /> Address x6 City <br /> Contractor`s Name License #.2 Phone <br /> TYPE OF WORK (Check): NEW WELL 'f DEEPEN ,/7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR'jX PUMP REPLACEMENT /? <br /> Other <br /> 4 DISTANCE TO NEAREST: SEPTIC TANK vp '' 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 /> � X_ Domestic/private Drilled . Dia. of Well Casing '• <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal S"O` <br /> Cathodic Protee,tion Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical 4 Surface Seal Installed BY: <br /> F PUMP INSTALLATION: Contractor aAlt <br /> i Type .of Pump :. H.P. 3 <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 of California pertaihing to or regulating well"construction. Within FIFTEEN DAYS <br /> after completion of my work on anew 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE 0, Q <br /> ---� <br /> _. .: . ._ i -(DRAW PL LAN ON REVERSE SIDE <br /> FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE ' /- <br /> ADDITIONAL COMMENTS: <br /> PHASE II G 5 CTIO PHASE III FINAL INSPECTION <br /> J INSPECTION BY DATE INSPECTION BY a DATE <br /> 1426 `: -• <br /> -,,:z Rev: 1-7 err —4/75 <br />