Laserfiche WebLink
FOE OFFICE USE: 160Y _ AN JOAQUIN LOCAL HEALTH DISTRIC G 7� <br /> 1 E. Hazelton Ave. , Stockton, Calif. <br /> r Telephone : (209) 466-6781 �- <br /> !APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2t,-45j�5� <br /> c <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued / �6 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION '� L— CENSUS TRACT <br /> ' OU <br /> Owner's Name Phone <br /> t — <br /> Address A �, City <br /> 1 <br /> .' Contractor's Name License �� �� Phone VZZl <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN%% RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR /% PUMP REPLACEMENT <br /> Other <br /> kDISTANCE 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 SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled r 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 i Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Tyypeet of Pump H.P. <br /> PUMP REPLACEMENT: %✓/ State Work Done j <br /> PUMP:RE�AIFt: / 7"Stafe-Work CDone <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 REPORT of ,'the well and notify them before putting the well in use. The above y <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. : <br /> SIGNED TITLE <br /> � � • <br /> I DRAW PLb PLAN ON REVERSE SIDE) V _� •,,f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION 'ACCEPTED BY �h ' DATE 7 ,2,,� -7 G <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION 11 <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Gn <br /> E H 1426 Rev. 1-74' <br /> 3/ 2M \' <br />