Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH. DISTRICT Cir , <br /> -TOT'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. T� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _z 7sg/a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued :/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 N 1862 and the s� and eg►►�uula^tia s of the S/ann �Joaquin <br /> �Local <br /> Q Health District. <br /> JOB ADDRESS/LOCA CENSUS TRACT <br /> Owner's Name �- # Phone` :)_ r <br /> Address /191 009 <br /> Cit <br /> Contractor's Name Licensee 7APhone ~ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /-7RECONDITION /- DESTRUCTION /-7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other J-7 — t <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 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 /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> 400 <br /> PUMP .REPAIR: A State-Work Done � <br /> or <br /> ., <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ;a4 <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 <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 INSPECTION. <br /> SIGNED TITLE <br /> D W-P PLAN 'ON R.SE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL -COMMENTS: <br /> PHASE IV 5FORIFT INSPECTION PHASE III/FINAL -INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M: i. <br />