Laserfiche WebLink
ATH. DISTRICTSAN JOAQUIN LOCAL <br /> I <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. <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. 1C862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION7.,Z,4 k,,., 6 7-g,483ENSUS TRACT <br /> Owner's Name f [J Phone <br /> Address City 6191 <br /> Contractor's Name ,1 License # p10 Phone0� <br /> i' <br /> _ r <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION f_1 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other f_1 <br /> DISTANCE TO NEAREST: -- SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PUT, 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 �I <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 /> - - - Y <br /> PUMP INSTALLATION: Contractor � ¢" <br /> Type of Pump ,� - --- H.P. / <br /> PUMP REPLACEMENT; `/ / - State- Work'Done � <br /> PUMP ,REPAIR: / /"- State Work Done• f <br /> DESTRUCTION OF WELL. We1l1 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 G OUTING AND FIN INSPECTION. <br /> SIGNED TITLE <br /> 19 <br /> MAW- PEW PLAN ON RE ERSE SIDIJ <br /> F9A PARTMEN USE ONLY E <br /> PHASE I <br /> APPLICATION ACCEPTE L.J /\60 7-/,,- DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P II/ N INSPECTI N <br /> INSPECTION BY . DATE INSPECTION BY DATE <br /> �J <br /> "n:.. <br /> E H 1426 Rev. '1-74 3/75 2 <br />