Laserfiche WebLink
L,--- 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 Permit No. 76-1r 0 <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 3oaquin ,I <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> ;3 ` CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> City ��� <br /> c� J - p Phone <br /> Contractor's Name License ��®60 <br /> i' <br /> TYPE OF WORK Check) : NEW WELL/ y/ DEEPEN '/ / RECONDITION_/_� DESTRUCTION <br /> PUMP INSTALLATIO /� PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY <br /> V SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> '`k PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE r TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' Cable Tool Dia, of Well Excavation <br />` Domestic/private Drilled Dia. of Well Casing � <br /> I Q <br /> Domestic/public E Driven Gauge of Casing <br /> Lj <br /> Irrigationd:� Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout t" <br /> t� Disposal Other"- n Other Information <br /> t Geophysical h_ _,� _ . , . . _Surface Seal`-Install , B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> PUMP 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 sand notify them before putting the .well in use. The above <br /> information isetrue to the-best of my knowledge and belief. I'WILL C FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING A FINAL INSPECTION. <br /> SIGNED TITLE <br /> ���,ee4 _ <br /> (DRAW PT; T PLAN ON RE LRSE SIlI� ' <br /> F. R DEPARTMENT USE ONLY <br /> ` PHASE I DATE b <br /> APPLICATION ACCEPTED BY <br /> k ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA II IN INSPECTI N <br /> INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> 3/7b 2M <br /> E H 1426 Rev. 1-74 <br />