Laserfiche WebLink
_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. r1 7"I7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuecPE L819 <br /> (Complete In Triplicate) <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. 11867s a the Rules and Regulations of the. San Joaquin Local Health Distract. <br /> J6f ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name � Phone ���I <br /> Address3�'�� , ie�ev xere7— - - - City <br /> Contractor's Name �iwr�{yIj/�L (� cr,rcr, � -r � License # Phone � <br /> t <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> !•f <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /4r'-{ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ��'�" CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINT .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 B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 2 <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING bLD A FINAL INSPECTION. <br /> SIGNED E•-ut TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> E H 1426 Rev. - I-74 <br /> 6!77 - <br />