Laserfiche WebLink
V/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)466-6781 — <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,/' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued i . 7 <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. 1062 and ,thejtules and <br /> Regulations of the Sac: Joaquin Local Health District, <br /> �dDyU � ze� <br /> JOB ADDRESS/LOCATION <br /> .p CENSUS TRACT <br /> Owner t s Name t Phone <br /> Address Z D <br /> Contractor's Name �� icens <br /> TYPE OF WORK (Check) : NEW WELL /ZT--IYEEPEN /_7 RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION /PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other /_7 , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT 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 Cable Tool Dia. of Well Excavation t <br /> 7�7omestic/private Drilled Dia. of Well Casing y. <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 Surface Seal Installed By: , <br /> PUMP INSTALLATION., Contractor Jf � <br /> Type of Pump .,.Z .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 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 .af my knowledge and belief. T WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUENG AND A FINAL INSPECT <br /> SIGNED TITLE <br /> ._... <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r��-C/ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z6_ , <br /> 6' <br /> E H 1426 Rev. 1-74 x/75 2M <br />