Laserfiche WebLink
SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 788�v <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 70 P <br /> x <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 andlthe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADD�SS/LOCATION CENSUS TRACT <br /> Owner's Name , • Phone y <br /> t <br /> Address Q1 EQ1 City <br /> Contractor's Name II LicensAjo. 4 PhongI5 <br /> TYPE OF'WORIK'{Cneek) NEV WELL / DEEPEN / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 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 12- <br /> 4-- <br /> 2.V► Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal S- <br /> Cathodic Protection _ Rotary Type of Grout ��'.�,p�s "N' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> H.P.-Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR:. State.-Work Done <br /> DES-TRUCTIONOF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />� 1 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 diem before putting the .well in use. The above 4 <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 /> E. SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)- <br /> FOR <br /> IDEFOR DEPARTMENT USE ONLY <br /> I PHASE I <br />. APPLICATION ACCEPTED BY DATE -2 , <br />` ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ;j' 1�_ r `7r <br /> 11177 2 <br /> E H 1426 Rev_ 1-74 a+7` /-ea' F -- - M- A <br />