Laserfiche WebLink
_ C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO& OFFICE USE: i 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION! FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued Z—/,7- <br /> (Complete In Triplicate) <br /> Application is hereby mads 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. I <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name G'r �t Phone �i��" y .. .._ <br /> Address 0 City' <br /> License ��- <br /> Contractor s Name # Phone V ,�v�-r L � <br /> _ � — �.'ti•� act <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN17 RECONDITION /7 DESTRUCTION 1'7 <br />'r PUMP INSTLATION PUMP REPAIRS <br /> ALPUMP REPLACEMENT 17 <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 SPECYFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Garage of Casing <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 B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> -PUMP REPLACEMENT-: r<--State-Work Do;ne�F�.= - <br /> PUMP .REPAIR: State Work Done <br /> IDE&TRUCTION OF. WELL: Well Diameter Approximate Depth <br /> r Describe Material and Procedure <br /> j <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 /> kWELL .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 AND A FINAL INSPECTION. , <br /> SIGNED TITLE 27y'A-,,v <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - .a <br /> J APPLICATION- ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> F PHASE II GROUT INSPECTION PHASE I FIN INSPECTION <br /> INSPECTION BY DATE, INSPECTION BY DATE <br /> i <br /> -- <br />