Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r FOH OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. ,` <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7f,3640 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> t° (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 -7 P ,4>- CENSUS TRACT <br /> Owner r �s Name Phone <br /> Address City <br /> Contractor's Name rcTrte1 - <br /> -in�s_S �. s._,r�i�� .._..-_.. License <br /> TYPE OF WORK (Check) : NEW WELL/L?�DEEPEN / / RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION /� PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <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 t (� <br /> Irrigation 'Gravel Pack Depth of Grout Seal w'T' <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: raSS <br /> PUMP INSTALLATION: Contractor r.%Au <br /> Type of Pump -- _... H.P. <br /> PUMP REPLACEMENT / / State Work Done /,. <br /> PUMP .REPAIR: <br /> State Work Dune i. <br /> DESTRUCTION OF WELL: Well Diameter ;,. Approximate Depth f <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sart.' Joaquin Local Healthistrict <br /> and the State of California pertaining t.o'or regulating well 'construction. Within FIFTE 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 notif .th-em 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 r' <br /> SIGNED TITLE <br /> DRAW. PLOT PLAN -ON REVERSE,SIDE) <br /> PHASE I / FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE p �, <br /> E H 1426 Rev. 1-74 7 - <br />