Laserfiche WebLink
4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> FOR 'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Per'mit No. -27--1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3- 7 <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 SannJ aaquin Local Health District, <br /> JOB ADDRESS/LOCATION � � � '/l �"-i ' _ CENSUS TRACT — - , <br /> ' Name � Phone h-3—.06�. <br /> Owners <br /> /�� _ <br /> Address City.,A p� <br /> Contracto Name . <br /> License J� �4 Phone ` <br /> t <br /> TYPE OF WORK (Check); NEW WELL /� DEEPEN /� RECONDITION / DESTRUCTION %T <br /> " PUMP =INSTALLATION I / PUMP REPAIR / / PUMP--REPLACEMENT <br /> _ .. 'Other `J% <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 WE L '. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well- Excavation (A <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 <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> \1'° <br /> PUMP REPLACEMENT: / / State Work Done 0 <br /> PUMP REPAIR: / / State.,Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth251 <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 FIFTtgm DAYS.. <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health. D stri4t 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 I$SPLCTIk. <br /> PRIOR TOG UTING AND 4=&INAL INSPECTION. <br /> SIGNED TITLE <br /> PL''ON. REVt RSE SIVE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL OOMMMTS: <br /> PHASE If GROUT INSPECTION. PHASE UIZLrINAL INSPECTION' <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> V76 . :. <br /> E R 1426 Rev. 1-74 <br />