Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT N� r <br /> FOE OFFICE 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 <br /> (Complete In Triplicate) <br /> Application is hereby made to"ithe 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 <br /> and° the Rulesa d Re ions 'of the San Joaquin Local Health District. <br /> ;9 ��eC y-two <br /> JOB ADDRESS/LOCATION r . <br /> CENSUS TRACT �� K <br /> Owner's Name Phone <br /> Addre_ ss Cit - <br /> Y y <br /> Contractor's Name € ; <br /> License 4�,; Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN,/_ ... ECONDITION / / DESTRUCTION f- <br /> PUMP ,INSTALLATION / / PUMP REPAIR '/—/ PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK& SEWER LINES 6,049 PIT PRIVY <br /> SEWAGE DISPOSAL sFIED , CESSP00L/SEEPAGE PIT OTHER <br /> PROPERTY LINE -.PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS �' <br /> ' Industrialrf Cable Tool, y_ .* Dia. of Well Excavation <br /> Domestic/private t Drilled �%i DI-a. of Well Casing <br /> Domestic/public DrivenGauge of Casing �t i <br /> Irrigation --------- <br /> Gravel Pack Depth of Grout Seal \ <br /> Cathodic Pr 101P �Rotary Type of Grout <br /> Disp6sal i ' T.! Other Other Information <br /> Geophysical _ Surface Seal Installed BZ:_,fAe <br /> p,6 <br /> s a . <br />'UMP INSTALLATION: Contractor ,`.S — <br /> TYPe ofPump H.P. <br />'UNP_'REPLACEMENT: # <br /> .State Work Done <br />'UMP -.REPAIR: / +/ State Work Done y <br /> ESjRUCTION OF WELL: W&,rl Diameter Approximate Depth <br /> i Des --ribe Material and Procedure <br />: .hd-teby agree to comply with all laws and regulations of the San Joaquin Local Health Distri-ct <br /> end the State of Califarnza'pertaining to or regulating well •construction. Within FIFTEEN DAYS <br />£ter completion of my work on a new well, I will furnish the San Joaquin Local Health Distriat a j <br /> FELL DRILLERS REPORT of the well and notify them before putting the well. in use. The above ' a <br /> nformation i true to the best,-.of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GRO ING AND A FI L INSPECTION. <br /> IGNED 4 ' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) r <br /> FOR. PARTMFNT USE ONLY <br /> HASE I <br /> PPLICATION ACCEPTED BY DATE <br /> DDITIONAL COMMENTS: <br /> PRASIE .II GROUT INSPECTION PHA II FI AL INSPECTIO <br /> NSPECTION BY KA f k DATE INSPECTION BY0 DATE <br /> ETH 1426 Rev. 1-74 pp 1f77 _ 2M . <br />