Laserfiche WebLink
� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> q Telephone: (209) 466-6781 <br /> II APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r $ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> ; Application is hereby made to the Sart Joaquin Local Health District for a permit to construct } <br /> ' and/or inetall the work herein described. This appi'Ication is made in compliance with San Joaquil <br /> ( County Ordnance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION " <br /> Owner's Name Phone <br /> Address �� t-Q-fs City. <br /> - -- ---- <br /> Contractor l 's Name (.11 Licenset�hone� <br /> TYPE OF WORK (Check) : NEW WELL/!' DEEPEN '/7 RECONDITION � DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR'/ 7_PUMP REPLACEMENT /7 <br /> Other /_ . . . . . -�- <br /> i 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 r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ndiistrial Cable Tool Dia. of Well Excavation /3 <br /> Domestic/private Drilled Dia. of Well Casing (4zSze <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel, Pack Depth of Grout Seal 119 <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'By: <br /> � jPUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> r <br /> PUMP REPLACEMENT / / State Work Done <br /> � �PUMP ,REPAIR: / J State Work Done 1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i 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-o my.rknowledge and belief. I WILL CALL FOR 'A -GROUT INRECTION <br /> PRIOR OUTING-AND NAL IN CTIA <br /> SIGNED E <br /> :J. (DRAW OT PLAN ON REVERU SIDE <br /> OR DEPARTMENT USE ONLY <br /> .PRASE I �0 <br /> `APPLICATIpN ACCEPTED BY DATE /- :2 4 <br /> f ADDITIONAL COMMENTS: <br /> �, PHA ROUT INSPECTION PHASE I I INAL INSPECTION <br /> ;INSPECTION BY DATE 7 -3? V- 2 _ INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 r! ,_ - - ---- <br /> ------ h/75___2M <br />