Laserfiche WebLink
6 1O.C. SAN JOAQUIN LOCAL HEALTH DISTRICT ----- <br /> FO FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �f �s <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.m 1862 and the Rules and <br /> Regulations of the San Joaquin Local Health District, <br /> -- <br /> JOB ADDRESS/LOCATION , - <br /> cC �m .✓ CENSUS TRACT <br /> VV <br /> ifi a p aVie P4^ <br /> Owner's Name b yh ziPhone <br /> Address I� B Ch Cita r y[ <br /> f <br /> Contractor's Name 0,4/ License lel hone G ,6 <br /> TYPE OF WORK (Check): NEW WELL /? ~DEEPEN-'/_/ RECONDITION /_� DESTRUCTION /_7 <br /> ALJ <br /> PUMP INSTALLATION / /' PUMP REPAIR / / PUMP REPLACEMENT W <br /> R Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY '4 <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 _ . t Cable Tool Dia. of Well Excavation <br /> )( .Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ' i- Rotary Type of Grout <br /> r. Disposal € Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION.- Contractor <br /> Type 6f ,Pump - I / H.P. <br /> PUMP REPLACEMENT- S-tate,Work Dane OF ,�_� �,�� <br /> i <br /> PUMP '.REPAIR: "/ / State-Work Done <br /> E&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 constru6tion. Within FIFTEEN D <br /> after completion of my work on a new well, I will furnish the. San Joaquin Local Health Distric <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- myw g an belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T ING AND A FINAL I t(? <br /> SIGNED f TLE - <br /> (E&PLOT PLAN ON REVSRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ' DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION f PHASE 4FINAL INSPEC ION <br /> INSPECTION BY DATE INSPECTION BY DATE �7 5 <br /> 1 E H 1426 Rev. 1-74 1-74 7M <br />