Laserfiche WebLink
Lf5 SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> FOA OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR -WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 -I1 SY/:, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/7 7y <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 Joaqu17 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner`s Phon(k <br /> Address <br /> C,,..,,ity <br /> Contractor's Name i�''� � , /���, License 044" �Phone�/�OL <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /+< PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ,, SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT-zz�/OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC 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 04 <br /> Disposal Other Other Information <br /> Geophysical `�/� /Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor /l0r 2r ,4: /?iyy�s <br /> Type of Pump )r..' _ �, , r.__ H.P.- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: . /7 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 District' a <br /> WELL DRILLERS REPOR ,Arf) the well and notify them before putting the well.A use.. The above <br /> PRIOR <br /> information <br /> ion is true to the best of my owledge and belief. I WILL R A GROUT" INSPECTION <br /> 'N T <br /> SIGNED TI <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY U�/( DATE q_17-)y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -- ,- ,,/ <br /> ! E H 1426 ''"Rev. 1-74 1-74 2M <br />