Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <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. l -:27 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued y 7 <br /> (Complete In Triplicate). <br /> Application is hereby made to the San Joaquin-Local Health District for a permit to construct <br /> 7and/ r install the, work herein described. This application is made in compliance with San Joaquin; <br /> C my Ordinance .No. 1862 and the Rules and .Regulatio of: the San Joaquin L al .Health District. <br /> JOB�ADDRE SLOCATIO Sg¢ �� � � �eCENSUS TRACT , <br /> Owner's Name Phone i <br /> Address D , r� U /e'I City <br /> i <br /> Contractor's Name ,A License # / '--,`�ad�'Phone -7�79 <br /> i <br /> Z. <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / 4�RECONDITION / / DESTRUCTION /_7 <br /> € PUMP .INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT <br /> Other <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 Cable Tool Dia..,of Well Excavation <br /> _ Domestic/private Drilled ' Dia. ,,of-Well Casing , <br /> Domestic ~ <br /> /public Driven _ Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Y Other Other Information . ' <br /> Geophysical 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 6z leI <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. wel.l in use.. . The above <br /> information is true to the best'of my knowledg and E ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE I ,f�. <br /> SIGNED YTLE V <br /> (D P OT PL ON REVE SE .SIDE) <br /> F DEPARTMENT USE ONLY r <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL, COMMENTS: <br /> PHASE II G UT INSPECTION. PHASE III/FI.NALINSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3-/ <br /> E H 1426 Rev- 2-74 b/77 2M <br />