Laserfiche WebLink
,r' 4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. !� <br /> 4 ,� <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 J'oaqui <br /> County Ordinance No. 1862 and the Rules and' Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a CENSUS TRACT <br /> Owner's Name Phone ';2. 1 <br /> Address Y �v ,S� ,.�C City` r Q C / d <br /> Contractor's Name jjLicense # OC1t Phone qr� ��! <br /> F; <br /> TYPE OF WORK (Check): NEW WELL DEEPEN -/7 RECONDITION J f DESTRUCTION (7 <br /> PUMP INSTALLATION/_/ PUMP REPAIR/W, PUMP REPLACEMENT <br /> Other-L-7- <br /> DISTANCE <br /> ther-,/_/DISTANCE TO NEAREST: SEPTIC-TANK ZK0 SEWER LINES PIT PRIVY <br /> + A SEWAGE DISPOSAL FIELD CESSPOOL-/SEEPAGE PIT OTHER, <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL"N`t.: PUBLIC DOMESTIC WELL", <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i Industrial Cable Tool Diaof Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven . Gauge <br /> Irrigation Gravel Pack Deph o £ 3GroutgSeal V ON <br /> i Cathodic Protection Rotary Type of Grout <br /> Disposal Other h Other Information <br /> Geophysical- Surface SeaY"Installed B <br /> c <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: . // State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> IBES;TRUCTION OF WELL: Well, Diameter <br /> r _ Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply'wi.th 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 s <br /> WELL DRILLERS REPORT of :the well and notify them before putting.. the .well in-use.. . The above <br /> information is truo the-best of- my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING- A FINAL INSPECTIO <br /> 'SIGNED TITLE <br /> W OT PLAN ON REVERSE SIDE <br /> PHASE I ., <br /> OR DEPARTMENT USE ONLY <br /> ! APPLICATION ACCEPTED BY DATE <br /> ' ADDITIONAL COMMENTS: -- <br /> PHASE IjAA6&E-1N0EcTibN <br /> PHASE III- FINAL INSPECTION <br /> . INSPECTION BY ��D E / /Z INSPECTION BY T . ..r.r DATE40�11V <br /> -x •�� <br /> . E H 1426 Rev. 1-74 1./4C vju <br />