Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 +p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit NO.yZ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Bate Issued -31, 70 <br /> j (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Distract 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 SIS ® CENSUS TRACT <br /> Owner's Name Phone �l <br /> ��- Address:• �.� /_f.._. ,. _..., - _� 3 . _ , -City .. <br /> Contractor's Name <br /> License <br /> TYPE OF WORK (Check) : NEW WELL /G}-�EEPEN / / RECONDITION / / DESTRUCTION / 71 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /� •a, -� <br /> — — - . --- � , � s <br /> other I I <br /> DISTANCE TO NEAREST: SEPTIC TANK _IW SEWER LINES 4Q PIT PRIVY a <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT PTHER ° <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> J. <br /> INTENDED USE TYPE OF WELL �� CONSTRUCTION SPECIFICATIONS, <br /> Industrial Cable Tool J Dia. of Well Excavation <br /> Domestic/private Dridied'% -4,1 Dia. of Well Casing f <br /> t Domestic/public _�7 _briven�- Gauge of Casing <br /> �� Irrigation-w- --~- - 'Gravel 'Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout (G` <br /> Disposal Other t Other Information _` <br /> h <br /> Geophysical Seal Installed B �� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �--' H.P. <br /> f� <br /> PUMP REPLACEMENT: / / State Work Dane <br /> PUMP .REPAIR: / / State Work Ione / <br /> fDES•TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations o.f-:the San Joaquin Local Health -District <br /> and the State of California pertaining to, .or; regulati� -i .well:•construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well; Twill furdi,W7the San Joaquin Local Health.District a <br /> WELL DRILLERS REPORT of the well and notify them before "Utting-the- well in use.. The above <br /> information is true to the best of my knowledge anbelief. I WILL, CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO AND A FINAL INSPECT _ <br /> SIGNED TITLE ` <br /> DRAW'PLOT PLAN ON REVERSE SIDE) LL <br /> f %FORS DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY '' DATE <br /> ADDITIONAL COMMENTS: Y <br /> PHA5E II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE _ INSPECTION. BY <br /> DATE <br /> - 'J <br /> of77 _ 2m ,1 <br /> E H 1426 Rev. - I-74 <br />