Laserfiche WebLink
Y • V <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 11"; � <br /> FOE�O�'FI E USE: 1601 E. 'Hazelton Ave:-$ Stockton, Calif. MQ(�;jo/z <br /> ,l <br /> 'Telephone: (209.) 466-6781 fN� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit No. / � <br /> f THIS-PERMIT EXPIRES 1'riYEAR--FROMWDATB-ISSUED, - -Date Issued <br /> (Complete In Triplicate) <br /> ApplicaCian is hereby made to the San Joaquin:Local Health District for a permit tO COnstruct <br /> and install the work herein described. This application is made in compliance with San <br /> County Ordinance No.' 1.862 and the Ruledand Regulations of the San Joaquin Local Health District.1 ict. <br /> � :TOB.ADDRESS/LOCATION <br /> r _ CENSUS TRACT <br />' Owner°s Name a } <br /> F Address Phone <br /> f City <br /> Contractor's Name 24L `"�' <br /> License I ' Phone <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN ,/-• RECONDITION F7 DESTRUCTION /7 <br /> PUMP INSTALLATION IV PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK, <br /> SEWER LINKS PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMEOTHER <br /> INTENDED USE STIC WELL PUBLIC D T <br /> PUIC WELL-�� <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool r <br /> Domestic Dia. of Well Excavation <br /> /Private i�� Drilled Dia. of Wel]. Casing <br /> Domestic/public _�� Driven Gauge of Casing <br /> Irrigation � Gravel Pack Depth of Grout Seal � <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal <br /> Geophysical Other Other, Information <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 3 <br /> Type of Pump a I <br /> A.P. <br /> PUMP REPLACEMENT; / / State Work Done <br /> PUMP !REPAIR: - . . ; .. <br /> L7 State Work Done <br /> ESTRIICTION OF.WELL: - -Wel-l-Diameter <br /> ` _ } ~�� ,,Approximate Depths - <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the an 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 GROUT NG AND A F NAL INSPECTION; <br /> SIGNED <br /> DRAW PLOT 'PLAN ON 'REVERSETLE S IDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br />�'P� L TION ACCEPTED BY � <br /> ADDITIONAL_ COMMENTS; DATE // / 7- 77 <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE PHA E /FIN INSPECTION <br /> INSPECTION BY TE DA / -z- <br /> L E H 1426 Rev. 1.-74 . '. . .. r h , } <br />