Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF: OFFICE USE: V 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 -7� <br /> j� (Complete In 'Triplicate) <br /> Application i$ 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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION G, -CENSUS TRACT ; <br /> Owner''s- Name Phone 36 <br /> ay <br /> Address <br /> City " <br /> 1 Contractor's Name --- ��L.� - ,,� License #14,:232-3 Phone_?CL-_Vr3f- <br /> TYPE OF WORK (Check): NEW WELL'/_7 DEEPEN '/7RECONDITION /7 DESTRUCTION /7 <br /> " <br /> Pump 1INST]A LATION / / PUMP REPAIR/ PUMP REPLACEMENT f7 <br /> Other L-1 . . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER 'LINES PIT PRIVY <br /> i <br /> SEWAGE,.DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p PROPERTY_�LINE =' PRIVATE DOMESTIC WELL' - PUBLIC DOMESTIC_WELL <br /> INTENDED-USEPE."OF-WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial . . Cable Tool Dia. of Well Excavation <br /> 'Domestic/private ` � Drilled Dia. of Well Casing +4 � <br /> Domestic I. <br /> J.public Driven Gauge of Casing <br /> Irrigation Gravel: Pack, [ Depth. of, Grout Seal <br /> Cathodic Protection 4 Rotary_.,,� [, i Type"bf.Grout <br /> Disposal Other Othexz-nformation <br /> Geophysical urface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> YPe I.of Pump H.P. <br /> 9 0 <br /> PUMP REPLACEMENT: / / State Work Done - f <br /> PUMP '.REPAIR: S.tate Work Done 64��_a A <br /> " <br /> i <br /> DESTRUCTION 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 <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.. y..knowledge and belief. "I WILL CALL FOR A 'GROUT INSPECTION <br /> ; PRIOR TO GROUTING AN AFI AL I CTION. <br /> y SIGNED ;TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ;ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY <br /> idDATE <br /> ADDITIONAL COMMENTS. s R <br /> C11- <br /> 'PHASE II GROUT--INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION-BY., � -,- _ DATE /•� <br /> E H 1426 �v Rev. 1-74 <br /> li/7K 9M <br />