Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � liJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -�4?r1 <br /> p (Complete In Triplicate) <br /> Application is' lereby 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 Joagan <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District.. <br /> JOB ADDRESS/LOCATION L� F ���� _ CENSUS TRACT F` <br /> Owner's Name Tl . �. , Phone V6 3 - ff <br /> Address L City �T�o�lC moo _ <br />' Contractor's Name License # Phone <br /> t <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_% RECONDITION /% DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> / / / / PUMP REPLACEMENT /_7Other -�} -v s� <br /> DISTANCE TO NEAREST: SEPTIC TANK r r F <br /> 1Q�t SEWER LINES ��PIT PRTVX;,..;, • f <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT a OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL. PUBLIC DOMESTIC .WELL <br /> INTENDED USE- ;' TYPE OF WELL CONSTRUCTION 'SPECIFICATIONS v� <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of We11'Casing ' <br /> Domestic/public i Driven - <br /> Gzu�e of <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection Rotary Type of Grout <br /> z YP .q <br /> Disposal ` Other .�Otfier Information ' <br /> Geophysical Surface 5ea1 Installed B <br /> PUMP INSTALLATION: Contractor w <br /> " Type of Pump <br /> .: H.F. <br /> PUMP REPLACEMENT: ; <br /> State Work Done <br /> PUMP 'REPAIR: /; / S.tate Work Done . <br /> DESTRUCTION OF WELL: Well Diameter k <br /> /" Approximate Depth � r <br /> Describe`M,a,terial and Procedure <br /> I hereby agree to comply Vith all laws and regulations of the San Joaquin Local Health istrict <br /> and the State of California pertaining to or regulating well •'construction. Within FIFTEEN ,.DA.YS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distri `''.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 GROUTING AN A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (D _ LO PLAN ON REVERSE SIDE)' <br /> ,,j FOR.DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY { <br /> ADDITIONAL COMMENTS: DATEi7� <br /> PHASE II, GROUT INSPECTION PHASE I I/FINAL INSPECTION <br /> INSPECTION BY G DATE ;1 -7 INSPECTION BY DATE . , <br /> E H 1426 Rev. 1-74 / < <br /> _ f.j7 <br />