Laserfiche WebLink
• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOU FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67 1 <br /> AP KAT/ION FORUC IO 0 PUMP PERMIT Permit No. <br /> T ISP T EXPIRES 1 YeAR tR99 DATE ISSUED Date Issued -21 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> sand/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 ._ CENSUS TRACT <br /> 1 <br /> Owner's Name igee cy- Phone <br /> .Address �� City <br /> ' License �2a - Phone. <br /> Gontractor's Name - <br /> t <br /> NEW WELL DEEPEN ' 7 RECONDITION /_7 DESTRUCTION <br /> TYPE OF WORK (check): I„�T I <br /> PUMP INSTALLATION jT PUMP REPAIR /_7 PUMP REPLACEMENT /_7 <br /> Other L/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> Y 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 /> Domestic/private Drilled Dia. of Well Casing <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 /> i t <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump Hop. t <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: /-7 State Work Done <br /> RES•£RUCTION 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-beet-of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU NG AND A F AL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY A7 DATE <br /> ADDITIONAL COMMENTS: <br /> -PHASE II GROUT INSPECTION P I NAL INSPECT ON <br /> INSPECTION by DATE INSPECTION BY ATE — 7 <br /> .1 "E R 1426 Rev. 1--74 1-74 2M <br />