Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TOR OFFT.CE U.,E: . 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 fora 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 /> JOI3 ADDRESS/LOCATION Q CENSUS TRACT <br /> Owner's Name MA , Phone ,- <br /> Address' 1 = City <br /> Contractor's Name onn,'pLicense #24pqqj Phone 3L,9­_ Q <br /> t <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION/ / DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/S AGE PIT '� � OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WEI1PUBLIC OMESTIC 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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By 46= <br /> PUI1? INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> e <br /> PUMP'REPLACEMENT: f / State Work Done <br /> PUMP .REPAIR: <br /> —/ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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 Distract 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 GROUT INSPECTION <br /> PRIOR TO GRQ TING AND FINAL INSPEC'T`ION. <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY x <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE 9 -2 -22 - <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHASE III/ INAL INSPECTION J <br /> INSPECTION- BY DATE INSPECTION BY DATE_ j 26 7 t <br /> E H 1426 Rev. - 1-74__ <br /> - � b1/77 - 2M� <br />