Laserfiche WebLink
FOISAN JOAQUIN LOCAL HEALTH DISTRICT �— <br /> rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 76/ <br /> .APPLICATION FOR WELL, CONSTRUCTION OR PM1P PERMIT Permit No. <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION /7�7 74 0? 2- �_s Us TRACT <br /> Owner's Name <br /> Phone 4e-51-- �,/a/ <br /> Address _ <br /> o City <br /> Contractor's Name License # <br /> Phone <br /> TYPE OF WORK (Check): NEW WELL /�1`/ DEEPEN /� RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION /&/ PUMP REPAIR /� PUMP REPLACEMENT /L <br /> Other j/ 7 <br /> DISTANCE TO NEAREST; SEPTIC TANK � SEWER LINES �_�. PIT PRIVY �a o <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 V <br /> Industrial Cable Tool Dia. of Well Excavation <br /> T Domestic/private Drilled Dia. of Well Casing N <br /> Domestic/public Driven Gauge of Casing .� •• <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRota � <br /> — �' Type of Grout <br /> Disposal . <br /> Other Other Information <br /> Geophysical — — Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor I &/1/ . <br /> Type of Pump <br /> II.P. <br /> PUMP REPLACEMENT: /XJ State Work Done <br /> PUMP 'REPAIR: /7 State Work Done <br /> MS-TRUCTION OF WELL: Well Diameter <br /> 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 puttingthe- 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 GROU I A F INS <br /> SIGNED <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> TITLE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL CON MEN TS: DATE <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY &10 DATE / 174 INSPECTION BY E — DATE <br /> E H 1.426 Rev. 1-74 <br /> �� . 1-74 9M <br />