Laserfiche WebLink
SAN-J.OAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE.. USE: ',- --- .6- .� <br /> Vr'v 1601 E. Hazelton Ave. , Stockton, Calif_. �• <br /> - -,- -elephon�L- 89-)°4fi6=57"81' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, -glgp <br /> THIS PERMIT EXPIRES 3 YEAR FROM DATE ISSUED Date Issued <br /> (Cori►plete In Triplicate) a <br /> Applicatiow is hereby ma a 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 Rmaes d Regulations o the San Joaquin L c 1th District. <br /> JOB ADDRESS%L ATION E <br /> �' CFsUS TRACT <br /> i p <br /> Owner's Name ' Phone �r033 <br /> Address I! City0 <br /> ` <br /> Contractor'S Name 6License �f' �� one <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR REPLACEMENT /_7 <br /> Other <br /> t. <br /> DISTANCE TONEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 1 <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL y CONSTRUCTION SPECIFICATIONS k <br /> Industrial 'k" , i Cable .Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public r Driven Gauge of Casing <br /> Irrigation �. Gravel Pack -Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor `' <br /> �F <br /> TYPe of 'Pump H.P. <br /> PUMP REPLACEMENT: . / !f/ State Work Don « <br /> MP REPAIR-E I� � <br /> PU ' <br /> /� State Work one �-:�•-� _ �} <br /> DESTRUCTION OF WELL: Well Diameter pproximate Depth �r <br /> Dk`scribe Material and Procedure d <br /> I <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Californt 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..knowled& and belief. I WILL- CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU NG AND A FINAL INSPECTIO <br /> SIGNED if TITLE Ap <br /> U (DRAW PL 'T' PLAN 'ON REMSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY c <br /> ' � DATE ;�-/3-7 <br /> ADDITIONAL COMMENTS: iM <br /> PHASE II GROUT INSPECTION PHAS , III/FINAL INSPECTION <br /> INSPECTION BY IM DATE INSPECTION BY yj DATE q-93.7) + <br /> 3/76 <br /> E H 1426 - Rev. 1_74...� � � � <br />