Laserfiche WebLink
1/ SAN JOAQUIN LOCAL. HEALTH DISTRICT .. <br /> FOE OFFICE USE: ' 1601 E. Hazelton Ave <br /> e. , ,Stockton,, Calif., <br /> Telephone: (209) 466-67.81' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> J <br /> THIS PERMIT 9XPIRES- 1 YEAR FROM DATE ISSUED Date Issued "7drl <br /> (Complete In Triplicate) <br /> Application is'Aereby 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 joaguii <br /> County Ordinance No: 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � <br /> � � CENSUS TRACT <br /> a <br /> Owner's Naive _w Phone <br /> Address Ci ,- <br /> Contractor's NameLicense/ a Phone <br /> TYPE OF WORK (Check) : yNEW WELL /_7 DEEPEN -/_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR 3KJ PUMP REPLACEMENT ) <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELLT <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. <br /> Industrial Cable Taal Dia. of Well Excavation <br /> Domestic/private #i Drilled Dia. of;'Well Casing t <br /> Domestic/public A Driven Gauge 6f Casing x � <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 /> PUMP INSTALLATION: Contractor <br /> Type` of Pump H.P,.' <br /> t <br /> PUMP REPLACEMENT: / / State Work Done ` r <br /> PUMP.REPAIR: State Work Dane -- Y -- Y <br /> DES-TRUCTION OF WELL: Well Diameter_ Approxi .ate' Depth <br /> ^ Describe Material and Procedure "'�� <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health 'i.st;riet <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<be' st _of_my.,*nowledge and belief, I WILL CALL FOR A GROUT INSPECTION - <br /> PRIOR <br /> NSPECTION "PRIOR TO GROUTING ANDA FINAL' INSPECTION' <br /> SIGNED' ,., h � p <br /> TITLE <br /> t t, � (DRAW PLOT PLAN ON REVERSE SIDE <br /> " " ► FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY'"`''' i DATE / 2_ 3 <br /> ADDITIONAL COMMENTS: d <br /> PHASE II GROUT INSPECTION PHAS ill/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H '1426 Rev. 1-74 .' <br />