Laserfiche WebLink
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. V-51-3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Y�0 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION E 'YlCENSUS TRACT <br /> Owner's Name ,� Phone `�� ✓ <br /> AddressWz. �z, City <br /> elllz� <br /> Contractor's Name License Phone . . . <br /> c.- <br /> TYPE OF WORK (Check) ; NEW WELL/? DEEPEN /T<l RECONDITION �V DESTRUCTION,/? <br /> PUMP INSTALLATION'. PUMP REPAIR-/ / PUMP REPLACEMENT /7 <br /> Other J-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK;�ZSEWER LINES PIT PRIVY f ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE .P.IT. . OTHER;. W <br /> PR0PrktY"LINS -LPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> - ..INTENDED USE TYPE OF WELL _ CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool "_ Dia. of Well Excavation- j <br /> Domestic/private. Drilled Dia,. of Well Casing te <br /> - Ir es-ticonublic Driven Gauge of Casing _ /2, <br /> Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Ins,, t, alledB _• <br /> PUMP INSTALLATION: Contractor <br /> Type of Pum H.P. <br /> PUMP REPLACEMENT; / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTIONOF WELL: Well Diameter Approximate Depth <br /> ® - - Describe Material and Procedure <br /> li <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local 4ealth 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 of- my knowledge and belief. I WILL CALL FOR A GRUUT. INSPECTION <br /> PRIOR TO GROUITING AND A F NAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLAN 'ON REVERSE SI E) <br /> {p.!° <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEDBY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E I NAL INSPECTIO . <br /> INSPECTION BY DATE INSPECTION BY DATE 6 �$ <br /> I <br /> 3/76 2M. 1 <br /> E H 1426 Rev. 174 .- <br /> . <br />