Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE ,USE: 160.1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7 g �� 4 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUNK.' PERMIT Permit No. 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 rl-f CENSUS TRACT <br /> Owners Name /41SP. Phone 3 / <br /> , <br /> Address A� City <br /> � a' <br /> Contractor's Name - License # _7j�Ahone tl <br /> i <br /> TYPE OF WORK(Check) ; DEEPEN / / RECONDITION /-7DESTRUCTION /7 µ 4 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /t:7 PUMP REPLACEMENT 1-7 <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 s <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-Grant-Seal r_ <br /> Cathodic Protection Rotary Type of Grout <br /> —Disposal f`, Other :. .Other Information <br /> Geophysical k Surface_Seal Installed By: . __.• <br /> PUMP INSTALLATION:, Contractor& ygl- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / V State Work Done <br /> _ k <br /> PUMP .REPAIR: State Work Done <br /> tN i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 4 <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 'constructi.on. , 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 <br /> information is true to the best of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING AND A FI AL INSPECTION. <br /> SIGNED TIT6LE- <br /> DRAW SPL T PLAN 'ON RE 1tSE SIDE) <br /> F <br /> PHASE I R DEPARTMENT USE ONLY <br /> r <br /> APPLICATION ACCEPTED BY c�. � DATE � <br /> ADDITIONAL COMMENTS: <br /> 4 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY L:! � DATE -_Z,3 <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />