Laserfiche WebLink
SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> FOL.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued_/,r-76 <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 San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION oo' 9&n t CENSUS TRACT <br /> Owner's Name X. Phone <br /> Address City <br /> Contractor's Name _ License # Phone , <br /> ` d <br /> TYPE OF WORK (Check): NEW WELL,-&7 DEEPEN/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR,/-7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _�ba SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER +y <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL - CONSTRUCTION SPECIFICATIONS f <br /> Industrial (' Cable Tool Dia. of Well Excavation -' W <br /> Domestic/private Drilled Dia. of Well Casing <br /> 147T- <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth--of-Grout-Seal- <br /> Cathodic <br /> epth-of Grout-Seal-Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surf ace Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> POMP REPLACEMENT: / / State Work Done " <br /> PUMP '.REPAIR: / / 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 knowledg. and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION.ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II -INSPECTY N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> /,( b ell <br /> E H 1426 Rev. 1-74 ti ���i i /(a,W► 4/75 . 2M <br />