Laserfiche WebLink
SAN JOAQUIN LOCAL HELTH DISTRICT <br /> EOE 0 ICE USE: 1601 E. Hazelton Ave. Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 1&d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedi <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 describA4. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the R agulationsoof the San Joaquin Local Health District. <br /> JOB ADDRESS LOC ON / � CENSUS TRACT <br /> Owner's Name ;k Phone <br /> 00, <br /> Address �" Cit <br /> rte. g . <br /> Contractor's Name �E ;M . „ License �y1 G� hon4L lo <br /> I� -5 <br /> TYPE OF WORK (Check) : NEW WELL /TJ DEEPEN L/ J RECONDI TO '-DES.TRUCTION /� T <br /> PUMP INSTALLATION / / PUMP REP /! P -RkPLACEMENT / 7 <br /> yyL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC- TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY`f,INE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL F CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> ' Domestic/public Driven Gauge of FCasing <br /> Irrigation Gravel Pack Depth of ;Grout Seal <br /> Cathode Protection r ,Rotary Type of Grout <br /> Disposal Other ' ' �'' .` `;-0_ther .Information <br /> Geophysical Surface 'Seal Installed By: <br /> PUMP INSTALLATION: Contractor s <br /> TYPe of Pump H.P. <br /> F <br /> R <br /> PUMP REPLACEMENT: / / State`Work bone, <br /> ,,PUMP .REPAIR: �• State.-Work 'dTCe - !:Z 99 - <br /> ' DESTRUCTION OF WELL: Diameter <br /> '" ; Approximate Depth <br /> Describe Material and- Procedure, ' <br /> I hereby agree to com:JIM <br /> Ily with all laws and regulations of the SanjJoaquin Local Health District <br /> iand 'the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of myk 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 knowledgefand belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INSPECTION. � k. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE. SIDE) <br /> r k_ <br /> FOR)DEPARTMENT USE ONLY <br /> PHASE IYaA DATE U <br /> APPLICATION ACCEPTED BY <br /> ' ADDITIONAL COMMENTS: <br /> PHASE IIIMGROUT INSPECTION HA <br /> PS II/ INAL INSPECTIO <br /> INSPECTION BY :i� ' DATE INSPECTION BY DATE <br /> ��. /77 7 2M� <br /> E H 1426 Rev. 1=74 - - - <br />