Laserfiche WebLink
SAN JOAQUIN LOCAL REALTH DISTRICT <br /> FOFfOFFICE; USE: �" 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone : (209) 466-6781 <br /> ZLI APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,7-,/ 6J PO <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 -76 CENSUS TRACT <br /> Owner's Namer ��,� �!� Phone <br /> .� 151510 <br /> Address City ,ode_ 2lea <br /> Contractor's Name License #C2�hone <br /> TYPE OF WORK '(Check) : NEW WELL / / 'DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7AL <br /> • PUMP INSTLATION 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°- i TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial s " Cable Tool ,Dial` f Well Excavation <br /> Domestic/pkivate Drilled Dia. of Well Casing <br /> Domestic/public , Driven x^. Gauge of Casing <br /> Irrigation �. Gravel Pack r Depth of Grout Seal <br /> Cathodic Protection , Rotary Type of Grout <br /> f <br /> Disposal Other Other Information <br />'f Geophysical Surface Seal Installed By:_____ <br /> i PUMP INSTALLATION: Contra'ct'or " <br /> _ <br /> Type of�Pump:, <br /> s, <br /> PUMP REPLACEMENT: X State Work Done <br />! PUMP .REPAIR: / / State Work Done <br />� DES•TRUCTION 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 of my knowledge and belief. I WILL CALL FOR A.GROUT INSPECTION <br />:PRIOR TO GROUTIM ANDA INALAINSPEQTJON. <br /> SIGNEDt TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)4 ; <br /> FOR DEPARTMENT USE ONLY <br />!PRASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN ECTION P III N INSPECTIO <br /> - INSPECTION BY DATE INSPECTION BY ATE <br /> k <br /> 1177 . 2M <br />