Laserfiche WebLink
� r . <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: �f�_J 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 /> 1 County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District.; <br /> JOB ADDRESS/LOCATION �`D/4�� CENSUS TRACT <br /> ` Owner's Naive Phone l" � -- 03/ <br /> AddressCity <br /> Contractor's Name _� . License Ito,—o Phone <br /> T <br /> I TYPE OF WORK (Check) : NEW WELL -/g DEEPEN/ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /{� -PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PIT OTHER \ <br /> PROPERTY LINF�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 C 'r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ Gravel Pack .Depth of Grout Seal c� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information 111 <br /> Geophysical Surface Seal Installed By: /C .7,ez-a <br /> ` a <br /> PUMP INSTALLATION: Contractor. ., /{��C�G/< <br /> Type of Pump H.P. <br /> a • <br /> PUMP REPLACEMENT: .' / -/ State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> E Describe Material and Procedure <br /> I hereby agree. to comply with all laws and regulations offthe San Joaquin Local Health District <br /> and the State of/California pertaining to or regulating well'construction. Within FIFTEEN DAYS <br /> I after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> k WELL DRILLERS REPORT of,,the well and notify them before putting the well in use. The above <br /> information is ',true Wthe.best of my knowledge and: belief. I WILL CALL FOR A GROUT INSPECTION <br /> k PRIOR TO GROU IO ��'ONR <br /> SIGNED F ITLE D W PI: T' PLANE ERSE SID , <br /> FOR DEPARTMENT USE ONLY <br /> p PHASE I <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: - W dz­t 1 4 , <br /> n <br /> PHASE II GROUT INSPECTION ( F PHASE I I/FINAL INSPECTION <br /> ' INSPECTION BY DATE i y F INSPECTION BY D TE —� <br /> /2K <br /> ' . 'E H 1426 Rev. 1 .74 <br />