Laserfiche WebLink
Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0_K'ZFFICE 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. 1862 and the Rules and Regulations of the Sart Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Glt! CENSUS TRACT <br /> Owner's Name JEPhone <br /> Address _ City ' ' <br /> Contractor s NameV Y14 A Lt <br /> License hone <br /> TYPE OF WORK (Check): NEW WELL / /�DEEPEN '/7 RECONDITION %j DESTRUCTION 17 <br /> PUMP .INST LATION PUMF7 P REPAIR- PUMP REPLACEMENT f <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � .2 PIT PRIVY <br /> SEWAGE DISPOSA4T _FIELD OSSSF992:fSEEPAGE PIT/► '-& OTHER <br /> PROPERTY LIN RIVATE DOMESTIC WELL�� PUBLIC DOMESTIC WELL '~� \� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 /> Aerw- <br /> Disposal Other Other Information <br /> Geophysical r� Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT /7 State Work Done <br /> PUMP .REPAIR: /7 State Work Done . <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 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 GROUTING AND A FINAL INSPE i!���� SLE <br /> SIGNED <br /> DRAW P P N REVERSE SIDE)--- <br /> FOR DE.PtIRTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 01-7 <br /> G <br /> ADDITIONAL COMMENTS: ' <br /> PHASE I OUT INSPECTIO PHA$E I INAL INSPECTION <br /> INSPECTION BY DATE Q - INSPECTION BY DATE 2r 76 <br /> E H 1426 Rev. 1-74 <br /> 4/75 2M <br />