Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone :P (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. — '3A40) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> F (Complete In Triplicate) <br /> Application is Aereby- made' to' the San Joaquin Local Health District for a permit to constru <br /> and/or install the work herein described. This application is made in compliance with San Joaquin ` <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . <br /> CENSUS TRACT <br /> Owner's Name f <br /> Phone 1` <br /> Address <br /> City f <br /> Contractor's NameA AAF License phone �,3k_ ,s <br /> An <br /> TYPE OF WORK (Check) • *NEW WELL DEEPEN /_/� RECONDITION _/ / DESTRUCTION /_7 �1 <br /> PUMP INSTAL-LATION V PUMP REPAIR/ / PUMP REPLACEMENT <br /> /? <br /> Other-/77/- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL .FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY ;LINE -- P$IVATE DOMESTIC WELL PUBLIC .DOMESTIC WELL <br /> INTENDED USE TY.PE`"OF WELL ; .CONSTRUCTION SPECIFICATIONS <br /> - 4.ti <br /> Industrial Cable Tool Dia. of We11..Exca,�7ation Z4V { <br /> Domestic/private I Drilled Dia. of"Well Casing m c u <br /> Domestic/public Driven Gauge of Casing �. <br /> Irrigation Gravel Pack Depth of Grout'_ Seal <br />_-- - Cathodic Protection. I Rotary Type of Grout, <br /> Disposal. I Other Other Information <br /> Geophysical Surface Seal Installed By.: <br /> ` 'C+ <br /> A. g F� �J 1 <br /> ur�T' INSTALLATION: Contractor <br /> Type of►Pump <br /> u REPLACEMENT: / / State Work Done <br />'UMP '.REPAIR: State.:Work Done <br />�5)TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Hereby agree to comply with all laws and regulations of the San Joaquin Local Health District I <br /> n�the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> fter completion of my work' on a new well, I will furnish the San Joaquin Local Health District a <br />'ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation is true to the nest o y knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 4IOR TO GROUTING AND A N I CTION. <br /> IGNED TITLE I y <br /> (DRAW-PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> RASE I <br /> PPLiCATION ACCEPTED BY ��� / DATE ,a-7_6"'�� <br /> DD;ITIONAL COMMENTS: I - -- —R-- <br /> PHASE II GROUT INSPECTION / PHASE FTN INSPECTI <br /> NSPEGT,ION BY DATE /� INSPECTION BYDATE 7' <br /> E H 1426 Rev. 1-74 - w - 1177_ <br />