Laserfiche WebLink
r ' <br /> i t7 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR�OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Dat <br /> E e Issued <br /> ' (Complete In Triplicate) <br /> Application is hereby made jo the San Joaquin Local Health Distzict for a permit to construct <br /> i 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 <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address I v <br /> City ' <br /> Contractor's Name '� ) 33dv4,H_ . <br /> License Phone <br /> TYPE OF WORK (Check): NEW WELL - DEEPEN '/? RECONDITION /7 DESTRUCTION f7 <br /> } PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT f7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /� SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD _10 D CESSPOOL/SEEPAGE PIT OTHER— <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL "- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �}3 <br /> Industrial Cable Tool Dia. of Well Excavation J <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /:X— <br /> Irrigation Ji/Gravel Pack Depth of Grout Seal <br /> Cathodic Protection —V Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: ZP <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump. H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `REPAIR: /? State Work Done" <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth 0-,05— <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-bgst of my knowledge and belief. I WILL CALL FOR A'GROUT INSPECTION <br /> PRIOR TO GROUTING AND AINA12 INSPECTION. <br /> SIGNED TITLE <br /> iz DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY . r1\-\DATE <br /> C. ADDITIONAL COMMENTS:. t <br /> PHASE W GROU INSPECTION PHASE FIN `INSPECTION <br /> INSPECTION BY DATE 2 Z�'� INSPECTION BY DAT <br /> E H 1426 Rev.` 1-74 <br /> 1-74 2M <br />