Laserfiche WebLink
K' <br /> i. <br /> SAN JOAQUTN LOCAL HEALTH.DISTRICT <br /> FOOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> R <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ., Permit No.- zz <br /> d 7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued a- <br /> (Complete In Triplicate)Application is hereby made to the San Joaquin Local Health District for a .permit to construct <br /> i. App install the work herein described. This application is made compliance <br /> LocaleHealth District. <br /> an J <br /> and District. <br />. /or z . <br /> County Ordinance No. 1862 and the Rules and Regulations of the San 'Joaquin <br /> E. CENSUS TRACT <br /> 'JOB ADDRESS/LOCATION G <br /> -Phone3� <br /> Owner's' Name <br /> City <br /> Address <br /> ��- License Phone <br /> Contractor's Name <br /> i <br /> t <br /> TYPE OF WORK (Check) : STRUCTION /_7 <br /> NEW WELL /� DEEPEN PUMP RECONDITION <br /> INIl P[xMpEREPLACEMEN—1-7 <br /> PUMP INSTALLATION ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK UD SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' ESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPBLIC ECIFICATIONS <br /> ONS y <br /> j INTENDED USE TYPE OF WELL p <br /> i ation <br /> Industrial Cable Tool Dia. of Well Excav1 <br /> �( Domesticfprivate <br /> Drilled Dia. of Well Casing o <br /> -" Domestic/public Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> 05 <br /> Type of Grout <br /> Cathodic Protection �_ Rotary _ Other Information <br /> Disposal Other <br /> Geophysical �� Surface 5ea1 Installed B <br /> PUMP INSTALLATION: Contractor` H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ., / / State Work Done <br /> PUMP .REPAIR• / / State` Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter H <br /> Describe Material and Procedure <br /> i <br /> th all la%rs and regulations of3the San Joaquin Lo <br /> I hereby agree to comply wical Health District <br /> well <br /> and the State of California pertaining to or regulating construction. Within FIFTEEN DAYS <br /> after completion of my work new well, I will furnish the San Joaquin Local Health District <br /> notify them before putting the well in use. The above <br /> WELL DRILLERS REPORT of well and <br /> information is true toa bes <br /> ; " Fowl e 'and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT INSPECTIO <br /> TITLE <br /> ' SIGNEDi <br /> W Pi 'T PLAN 'ON REVERSE SIDE <br /> TMENT USZ ONLY <br /> PHASE INDATE <br /> APPLICATION .ACC B Ll�7UEHLl�✓ <br /> ADDITIONAL COMMENTS: i P I /FINAL INSPECTION <br /> PHASE II GROUT INSPECTI •N INSPECTION' BY DATE - <br /> INSPECTION BY DATE <br /> � -- pK.�.� 3/76 22M <br /> E H 1426 Rev. 1-74 <br />