Laserfiche WebLink
cva A SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. qL' <br /> Telephone: (209) 466--6781 �.��,rJ�(/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. / r <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 rdinanee No. 1862 and the Rules and Regulations of SaV Joaquin Local Health District. <br /> ,5 e5 1 L 2 <br /> JOB ADDRESS/LOCATION a - a ' �! / NSUS TRACT <br /> Owner's Name Phone <br /> Address 1 R t 6 A J City mo IA4 , <br /> Contractor's Name ems}0// License #1132;- —Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /-7 l� <br /> I <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 Fl_ <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 j <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor V <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done AS�,.j fes` <br /> DES-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 putting the well in use. The above <br /> information is true to the best of my knowZedRe and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL IN I <br /> SIGNED TITLE <br /> (D W PLO PLAN ON RIXERSE SIDE) <br /> FORS DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY J DATE a <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I I/F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - _57 <br /> -? <br /> E H 1426 Rev. , 1-74 <br />