Laserfiche WebLink
{ —�—r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR, FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) x+66-6781 � <br /> t <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ` <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue d, <br /> k /�v �l' Complete In Triplicate) <br />£ Applic tion is hereby made t� the San Joaquin Local Health District for a permit to con <br /> ct <br /> and/or install the work herein described. This application is made in compliance with San uJoaquin <br /> County Ordi Pance No. 86 nd the Rules, end Re ulat(i%ns�. of the S n Joa uin Loca Hea th District. <br /> JOB AD' DRESLOrCATIO { -1 U 7 <br /> / N n CENSU TRACT <br />' Owner's Name <br /> � <br /> cJ /- Phone �� <br /> Address b/� 9s, C City <br /> Contractor's Name j` <br /> License ��,� � Phone - <br /> i <br /> 1 <br /> TYPE OF WORKCheck -- DE�._L,�-,_�.� <br /> ( ) : NEW WELL ) / =DEEPEN /�/ RECONDITION /? STRUCTION <br /> PUMP INST TION PUMP REPAIR / / PUN? REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO <br /> NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ^--�-- <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELLYCICONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> IF lez- <br /> Domestic/private DrilledDia. of Well. Casing <br /> Domestic/public Drivene Gauge of Casing <br /> Irrigation j Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ( Rotary Type of Grout <br /> Disposal j Other € <br /> Other Information <br /> I� Geophysical Surface Seal Installed By: <br /> INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done R <br /> PUMP_.REPAIR: 4—S,-ate-Work-Bone =T <br /> DESTRUCTION OF WELL: Well Diameter r(� <br /> Describe Material and Procedure Approximate Depth <br /> � r <br /> I her 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 DAIS <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 bF <br /> PRIOR TO GROUTING AND A FINAL INSPEC ION. belief. I WILL CALL FOR A GROUT INSPECTION <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: j DATE <br /> PHASE II GROUT INSPECTION PHASE I /FTN INSPECTI <br /> INSPECTION BY DATE INSPECTION B +Y / € <br /> � DATEI a , <br />- E H 1426 Rev. 1-74 <br />