Laserfiche WebLink
d SAN JOAQUIN,�CtA4 , 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. J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued 5?-j-7� <br /> (Complete In Triplicate) / F"3 --30'D -o7 <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 /> 1-7Cp3 .s • 04£-1 i-IT- <br /> JOB ADDRESS/LOCATION <br /> Liz- <br /> ,I ENSVS TRACT <br /> Owner's Name <br /> �� '`� Phone � <br /> Address - 0 s <br /> City <br /> &. <br /> Contractor's Name � License # Phone g%3� <br /> TYPE OF WORK (Check): NEW WELL &�7 DEEPEN. /7 RECONDITION / DESTRUCTION,/-7 <br /> PUMP INSTALLATIONIL/ PUMP REPAIR -/-7—PUMP REPLACEMENT /7 <br /> Other /% --- <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES <br /> ...5 c�... PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPO L/SEEPAGE PIT — OTHER <br /> PROPERTY LINE - PRIVAT& DOMESTIC WE PUBLIC DOMESTIC WELL W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation h <br /> Domestic/private Drilled Dia. of Well Casing 6>> <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation .Gr-avel Pack Depth of Grout Seal �, p <br /> Cathodic Protection Rotary Type.,of._Grout <br /> Disposal Other. Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor t "' ,.._.... . <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: /� State Work Done t <br /> DES�—TTRUCTI()N 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-ofmy.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A PI <br /> NAL INSPECTION. <br /> SIGNED - 1 TITLE <br /> {DRAW PLOT PLAN ON REVERSEISIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> - � . <br /> APPLICATION ACCEPTED BY - DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE'll GROUT:.INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATES -7/ INSPECTION BY DATE - 7 <br /> E H 142.6 Rev. 1-74 ; h/75 2M <br />