Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA.,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209}x,466-67$1 <br /> APPLICATION -FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �_5-3 1-79 <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 /> County Ordinance No._ 1/62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION A CENSUS TRACT <br /> Owner's Name C f <br /> Phone <br /> Address City <br /> Contractor's Name - - License #,���Phone - <br /> M � F <br /> TYPE OF WORK (Check x aNEW -WELL„X DEEPEN -/- /" RECONDITION° /fit-/� `AESTRiJCTION <br /> i;PUM� INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /? fi <br /> Other %/-'/M �A 3 y <br /> T v t: Ilk4 y #4Wtl <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE'DOMESTIC WELL.4M2�" PUBLIC DOMESTIC WELL <br /> INTENDED USE'S TYPE OF WELL CONSTRUCTION SPECIFICATIONS}" Yk <br /> Industrial =;; Cable Tool Dia. of Well Excavation ! <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing G <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection < Rotary Type of Grout � , <br /> Disposal p �� Other Other Information <br /> r , Geophysical Surface Seal Installed Bv: iA2W9 �\ <br /> f: <br /> PUMP INSTALLATION: Contractor zmy 0 Z__ 6 <br /> Type of Pump - H.P. U <br /> PUMP REPLACEMENT: / / tat Work Done j <br /> PUMP ':RE A R <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure k <br /> i'r'e <br /> t I hereby' agree to comply' with-all laws and regulations ofathe San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well•construction. Within FIFTEEN DAIS <br /> after completion of my work on a new well, I willfurnish theiSanj'Joaquin�Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the •welf in'use. The above <br /> information is true to .thp e t f my knowledge and belief. I WILL CALL FOR A ROUT INSPECTION <br /> PRIOR TO G ,OUTI D A N / SPECTION. l <br /> SIGNED TITLE Cc <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 71 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECaTIO BY DATE INSPECT;ON BY DATE <br /> ( f I. , <br /> E 1426 Rev 1-74 W <br />