Laserfiche WebLink
A M^ Lit+ SAN JUAQUZN LOCAL HEAL'1'11 <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> kdo derv, THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> S�} c (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 p CENSUS TRACT <br /> Owner's Name uf� Phone <br /> e <br /> Address (`�- City <br /> Contractor's Name c. „ License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION /0/ PUMP REPAIR / / PUMP REPLACEMENT /_ <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia. of Well Excavation p <br /> Domestic/private Drilled Dia, of Well Casing Q <br /> Domestic/public Driven Gauge of Casing r <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 <br /> Type of Pump s H.P. . <br /> PUMP REPLACEMENT: / / State Work. Done.. <br /> PUMP Rerl= State Work!ne O p <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 kn w d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ROUTING AND A FINAL INSP T <br /> SIGNED TITLE <br /> ffRAW P LAN ON RE SE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -22 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PffASE I INAL INSP IO <br /> INSPECTION BY DATE INSPECTION BY 7 DATE' <br /> E H 1426 Rev- 1-74 6/77 .` 2M <br />