Laserfiche WebLink
�v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFI USE: 1.601. E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1xYEAR .F.ROM 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 incompliance with San Joaquin' <br /> County Ordinance No. . 1$62 and, the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION : ._. �,� fpY�s�C�d-' '* CENSUS TRACT <br /> Owner Is Name - 1�"C I7 '!�'/ ,` Phone <br /> "Address r A:p City <br /> Contractor's Name License # j Phone <br /> 5r V­ <br /> - - -- — i <br /> J <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / 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 <br /> _ T Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Graver 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 �t <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j_/ State Work Done <br /> PUMP . ��t/ eJ&A/ <br /> / State Work Done �;,T" ;�,/ . <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�f knowled.ge� nd belief. I WILL CALL FOR. A GROUT INSPECTION <br /> "PRIOR TO GROUT-EG AND A FIAW, ECT N�. <br /> SIGNED - TLE <br /> (PYCEPLOT PLAN .ON R" SE SIDE) <br /> FO EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA /F NAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE 7� <br /> od I7 - 2M <br />