Laserfiche WebLink
.� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: .(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 -a#ld <br /> 77-/-7/�O <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 1862 and the Rules and Regulations. of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION :JPO SI E ;4 _ v .) ; <br /> a CENSUS TRACT DDS-- 2t O--1 U <br /> Owner's Name Phone <br /> 1 <br /> Address r <br /> City 1,�t <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN ,/-7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY q, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER L) <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> fNTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS f`q <br /> Industrial Cable Tool Dia. of Well Excavation ' <br /> Domestic/private Drilled Dia. of Well Casing rP <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal i <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 /> PUMP REPLACEMENT: f:7 State Work Done <br /> Y PUMP 'REPAIR: /-7 State Work Done ' <br /> ES•TRUCTION 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 puttingthe..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 AND A FINAL INSPECTION. <br /> SIGNED ` TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID _ - <br /> : w� FOR DEPARTMENT USE ONLY <br /> PHASE`'I, <br /> APPLICATION ACCEPTb BYto DATE ` ,7, -- <br /> ADDITIONAI: COMMENTS: r <br /> PHASE`II -GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY ,..e .` DATE INSPECTION BY DATE <br /> ~E H 1426 Rev. 1-74 1-74 2M <br />