Laserfiche WebLink
r _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OUTCE 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 Zi-.2- `7a <br /> f 3:1 (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Distract 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 San Joaquin Local Health District. <br /> • s c <br /> JOB ADDRESS/LOCATION RdjCENSUS TRACT <br /> Owner's Dame Phone <br /> € i <br /> Address 'r City <br /> Contractor f s Name ! ' License ��� Phoneg ---L"i <br /> y �,A <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP ;INSTALLATION / J PUMP REPAIR/ �/ PUMP REPLACEMENT J-7 Cn <br /> Other J J 1 <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGEDISPOSA FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> # INTENDED USE :TYPE OF WELL CONSTRUCTION SPECIFICATIONS - <br /> Industrial 1 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 V Rotary Type of Grout <br /> r Disposal II� Other Other Information <br /> Geophysical I Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of 'Pump H.P. _n_ <br /> PUMP REPLACEMENT: / / ,State Work Done' <br /> PUMP .REPAIR: / / State Work Done' <br /> � DES,TRUCTION OF WELL: Well,1Diameter. 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 notifythem 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 INSPECTION. <br /> SIGNED TITLE <br /> t (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ! S <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHAS, I GROUT INS CTION._ PHAS III FINAL INSPECTION <br /> INSPECTION BY ,,DATE Z -/778 INSPECTION BY DATE -Z-�7-�y <br /> o�,� <br /> E H 1426 Rev. - l-74 �� <br /> �G , go y <br />