Laserfiche WebLink
r ' - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFx,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> � l Telephone: (209), 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a-70 e l <br /> THIS PERMIT EXPIRES 1 YEAR.FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sun Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made incompliance with San Joaquin? <br /> County,Ordinance No. ,1862 and ,the Rules and Regulations of the San -,Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONCENSUS TRACT ' <br /> Owner's Name (' -- Phone <br /> Address City . _ <br /> Contractor's Name ' ` ' Licen e � j' Phon; l <br /> TYPE OF WORK (Check): NEW WELL/ZF-DEEPEN '/? RECONDITION /_7 DESTRUCTION %f <br /> PUMP INSTLATION / YPUMP REPAIR/7 PUMP REPLACEMENT /7 <br /> AL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Je O * 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 r Cable Tool Dia. of Well Excavation <br /> L_-Domestic/private Drilled Dia of Well Casing <br /> Domestic/public • l Driven Gauge of Casing <br /> Irrigation 4 Gravel Pack —Depth'�'6T' Grout Sea] <br /> Cathodic Protection '- Rotary /Type of Grout A-� _ <br /> Disposal F : Other ,-Other Informatio- n <br /> - ,Geophysical-. w�* t f` Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor .. .�` <br /> Type ,of Pump - H.P. .3 �l <br /> -- <br /> PUMP REPLACEMENT:.,,-`—/ / State Work Done <br /> PUMP .REPAIR: /_7 State Work Done ?j <br /> DESTRUCTION OF WELD: Well. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I h4/re tiy 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 /> afterc <br /> _.' ompletion 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.4the-beat-of- my knowl.edg@Xaid belief. I WILL CALL FORA GROUT INSPECTION } <br /> PRIOR TO GROUT G D A FINaaEPECTION. <br /> k SIGNED TITLE 7� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> e PHASE I <br /> i APPLICATION' ACCEPTED BY; �" - DATE <br /> ADDITIONAL COMMENTS: "' <br /> _ _ ._PHASE.-II--GROUT w INSPECTIQN; , \'�- ` PHAS I I INSPECTION <br /> �. INSPECTION BY DATE`SI�SPL�TION', ATE =t- <br /> r, + E H 1426 Rau. 1-74 <br />