Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOF, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- 4 ZZII <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> -Z7 <br /> Application is hereby made to the San <br /> (Complete <br /> Triplicate)In <br /> 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 /> JOB ADDRESS/LOCATION <br /> _ CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City <br /> Contractor's Name �w J <br /> License 4� .�j��� <br /> �D L Phone <br /> TYPE OF WORK (Check) : NEW WELL <br /> / / DEEPEN /_/ RECONDITION / / DESTRUCTION /7 <br /> AL <br /> PUMP: INSTLATION. `/ PUMP REPAIR I I -_PVJ <br /> Other REPLACEMENT <br /> /% <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PTT 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 /> L/ Domestic/private Drilled Dia, of Well Casing G` <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth- of Grout Seal <br /> Cathodic- Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Doane or V <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 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 />'RIOR TO GROUTI D FINAL INSPECT 0 , <br /> SIGNED TITLE -fJ)Tj <br /> (DRAW PLO PLAN ON REVERSE SIDE) •_-- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> kPPLICATION ACCEPTED BY <br /> P.DDITTONAL COMMENTS; DATE 7 7 <br /> PHASE II GROUT INSPECTION <br /> P S I/FI INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> E H 1426 Rev. 1-74 �7r17 H. <br />