Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 601 E. Hazelton.Ave. , Stockton, Calif. i <br /> Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 6;9-i—C ,�,J ,4�E. J (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 J�o0aqu:Ln Local-3 <br /> Health District. <br /> JOB ADDRESS/LOCATION - �. -'��i�C. <br /> --CENSUS TRACT <br /> rAy t /j,9/V <br /> Owner's Name * Phone �,�h3r <br /> t <br /> Address City <br /> Contractor's NameL651a License # () a Phone <br /> TYPE OF WORK (Check) : NEW WELL/F11' DEEPEN / / RECONDITION / / DESTRUCTION /_T <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /� r <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES --- PIT PRIVY <br /> SEWAGE DISP SFIELD CESSPOOL/SEEPAGE"PIT p R <br /> AL <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 �37'� <br /> f _ Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal Other Other Informatiogur3tA.h_� _ <br /> Geophysical Surface-Seal-Installed B <br /> A <br /> RUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ,f <br /> PUMP REPAIR: / / State Work_ Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �r <br /> � J <br /> ' Describe Material and Procedure ; <br /> t 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 /> k 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 /> BRIOR TO G UTING AND A YJNAL IN ECTION. <br /> �. <br /> SIGNED TITLE + ' ��. . <br /> (D P- T LAN `ON RE SE SIDE)T <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: YT <br /> PHASE II GROUT INSPECTION PHA2§ JILfin§AL INSPECTIO _ <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> , vim L� 3/76 2M <br /> E H 1426 Rev. 1-74 <br />