Laserfiche WebLink
lqr SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F06 OFFICE USE: 1641 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 27- <br /> THIS <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '��jo <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 Joaquir, <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/t0C*rNM CENSUS TRACT <br /> Owner's Name ,�yd ��� Phone J� <br /> Address <br /> City ' . <br /> Contractor's Name f License 7,�_Ahone� <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/7 RECONDITION /_7 DESTRUCTION /`T <br /> PUMP INSTALLATION PUMP REPAIR /? PUMP REPLACEMENT J <br /> Other /—I- -- . .. -- <br /> DISTANCE TO NEAREST: SEPTIC TAN <br /> K .�`C� -SEWER LINES �t'O � PIT PRIVY v <br /> SEWAGE DISPOSAL MELD CESSPOOL/SEEPAGE PIT �- OTHER <br /> PROPERTY LINE - RIVATE DOMESTIC WELL/_d_-11-1PUBLIC 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 /X <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal cid <br /> Cathodic Protection � Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed Bv: ,! <br /> PUMP INSTALLATION: Contractor S � j <br /> Type of Pump H,P. <br /> , <br /> PUMP REPLACEMENT /f/ State Work Done <br /> PUMP 'REPAIR: /_7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 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 INSPECTIO <br /> 71,74 <br /> SIGNED - E <br /> PLO SE SID Az/� <br /> FOR DEP TMENT�USEONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY , DATE <br /> ADDITIONAL COMMENTS: , <br /> PHAS II GROUT INSPECT 0ff PHAS i F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> t� f� 77 <br /> y E H 1426--- Rev. 1-74 7q. ?M 1i <br />