Laserfiche WebLink
b--owJ6A(1UIN LOCAL 11EAL'Til lilSTitlCl' <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif . <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION 0'R PUMP PER141T Permit No. 'ZZ-x)41) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date -ALZZ <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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Q ( CENSUS TRACT <br /> Owner's Name 1 _� `� Phone <br /> IV r <br /> r <br /> Address City <br /> Contractor's Name I License 4,22)6/ Phone <br /> TYPE OF WORK (Check) : NEW WELL _ DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC TIONS <br /> Industrial L_--t-able Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing fQ _ <br /> Domestic/public Driven Gauge of Casing C' <br /> ___L_.:� �rrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By :, <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / 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 an 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 true to the bes of my knowledge and belief. I WILL CA L FOR A GROUT INSPECTION <br /> PRIOR TO GR T N AN FIN NSP IBN. <br /> SIGNED TITLE <br /> (DRAW PIPT PLAN ON RE FRSE SIDE) <br /> FM DEPARTMENT USE ONLY <br /> PHASE { <br /> APPLICATION ACCEPTED BY t DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE � 12 <br /> E H 1426 Rev. 1-74 <br /> 3/76 Z'4 <br />