Laserfiche WebLink
'910 SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOBrOFFICE USE: X1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: , (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued /D- L,7-;U— <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 acid the Rules and Regulations of the San Joaquin Local Health District. <br /> :JOB ADDRESS/LOCATION CENSUS TRACT .. <br /> Owner°s Name ILI``_l � Phone <br /> Address' <br /> / City _ ..� <br /> Contractor's Name ' rtj ,�. License # Phone <br /> TYPE OF WORK (Check):.. NEW WELL /_7 DEEPEN _7 RECONDITION /? DESTRUCTION f7 : <br /> PUMP INSTALLATION � /?PUMP REPAIR PUMP REPLACmMENT %f <br /> } Other // -. <br /> DISTANCE TO NEAREST: SEPTIC{TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE STYPE OF WELL •CONSTRUCTION SPECIFICATIONS <br /> industrial 11 Cable Tool Dia. of Well Excavation <br /> Domestic/private ' ► Drilled <br /> —� r--��- Dia'. of Well Casing <br /> Domestic/public f ; Driven ! ..,—Gauge"of Casing 'F <br /> Irrigation �' � Gravel Pack Depth of Grout Seal <br /> ` Cathodic Protection 1 Rotary Type of Grou"t <br /> Disposal , j Other + <br /> Y„�� Other Information <br /> Geophysical <br /> a f . .. Surface Seal Installed Bv: . <br /> PUMP INSTALLATION:; Contractor fj <br /> a <br /> Type of Pumpu t <br /> H.P. <br /> PUMP REPLACEMENT: <br /> . . / / State-1Work Done <br /> PUMP MPAIR: /_7 <br /> State Work Done _ <br /> ES:TRU : r 'I <br /> CTIfN •F WELL: Wa11 Diameter Approximate Depth <br /> bescribe Material and Procedure ~- <br /> 1 <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_.isork on a new well, I will furnish the .San Joaquin Local Health District a i <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 WELL CALL FOR A -GROUT INS <br /> PRIOR TO ROUTING AND A FIN INSPECTION. PECTION <br /> q <br /> SIGNED i. <br /> TITLE <br /> (DRAW PIAT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> F + <br /> APPLICATION-ACCEPTED .BY " —DATE <br /> ADDITIONAL COMMENTS: 4 �, I <br /> • . `r �P. GROUT INSPECTION P S T <br /> INSPECTION BY /FINAL INSPECTION <br /> DATE INSPECTION BY DATE � - <br />, , <br /> E H 1426 Rev. 1-74 i <br />