Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i <br /> Telephone: (209) 466-6781 // <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. cTz -7 7v <br /> e <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 Z 2 CENSUS .TRACT <br /> _ 1 <br /> --� <br /> Owner's Name � ,,,�°�.�, Phone � <br /> Address " '' � � �� 45- city <br /> _ <br /> Contractor's Name".0 -t icense„ Y Phone-?Z, � � <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPENAi,�:I_,,,RECONDITION / -:;.� 'TRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> _ _ <br /> Other <br /> -- _ - _,J <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 ,able Tool Dia, of Well Excavation , <br /> Gio--l?�Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public _ Driven Gauge of Casing ` Q <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geo=physical Surface Seal Installed By: <br />, PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, . <br />' PUMP REPLACEMENT: / / State Work Done _ <br /> PUMP .REPAIR: /. / State Work Done <br /> DESTRUCTION OP WELL-"-.- t We11 Diameter Approximate Depth <br /> ...De-scribe Material and Procedure <br /> i I hereby gree 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 G°R T.; AND A FINAL INSP ION. <br /> SIGNED - TITLE <br /> s (DRAW PLOT-PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ";PHASE..I <br />! APPLICATION ACCEPTED BYE; DATE" c ) �7s <br /> ADDITIONAL COMMENTS,,. <br /> PHASEII GROUT INSPECTION' _, P I/ NAL INSPECTIO <br /> INSPECTION BY DATE .. , INSPECTION,,BY " y" o?4? - <br /> DATE <br /> E H 1426 Rev..,,.1-74 77 2M <br />