Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> FOR OFFICE USE:` 1601 E. Hazelton Ave. , Stockton, Calif. - <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Al <br /> (Complete In Triplicate) 4 <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 JoeQuin ) <br /> County Ordinance No. 1862 and the Rules and Regulations of. the San Joaquin Local Health District.'; , <br /> JOB ADDRESS/LOCATION Zc2, coj 3 ��, CENSUS TRACT ' <br /> Owner's Name ' 7' Phone <br /> ` 4 <br /> Address P0, City , <br /> Contractor's Name Ji r,1A ,, � ' License Phone35�=�$� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION /_7 �J <br /> PUMP INSTAL ATION /3 PUMP REPAIR / / PUMP REPLACEMENT /7 A <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSALI 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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> f <br /> PUMP INSTALLATION: Contractor��Yl '- <br /> YP , � — <br /> T e' of Pump . H.P. <br /> PUMP REPLACEMENT: <br /> / /� State-.Work-•bone <br /> PUMP .REPAIR: State Work Done <br /> DES'TRUCTI'ON 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 Ga2LLIING AN INAL INSPECTION. <br /> SIGNED - - - r --TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLYPHASE I <br /> ' <br /> APPLICATION ACCEPTED BY 1 r N DATE <br /> ADDITIONAI�'COMMEN.T.S-: - . .. <br /> PHASE II GROUT INSPEZTION PHASE ,III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 77 <br />' E H-1426 Rev. 1-74 - - _ - - _ - -- <br />