Laserfiche WebLink
FOF OFFICE USE' SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued T <br /> Applica (Complete In Triplicate) <br /> tion 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 Joaquir <br /> County Ordinance No. 1862 and- the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION (1� <br /> e CENSUS TRACT <br /> Owner's Name f� <br /> Phone <br /> Address. g <br /> city � l <br /> f Contractor's Name d'D <br /> License #<9 Z2�,VVPhone 162,4?07 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_% RECONDITION <br /> DESTRUCTION /-7 <br /> f PUMP INSTALLATION PUMP REPAIR PUMP REPLACEMENT . /� <br /> Other <br /> DISTANCE TO NEAREST: <br /> SEPTIC TANK PIT PRIVY <br /> - -, SEWER LINES <br /> SEWAGE DISPOSAL"FIELD ' 13 � <br /> y CESSPOOL/SEEPAGE PIT OTHER Q <br /> _ _�PROPKRTY-LINE_-._. PRIVATE-DOMEST,IC WEL <br /> INTENDED USL PUBLIC DOMESTIC�WE L <br /> { E TYPE OF WELL CONSTRUCTION:SPECIFICATIONS O <br /> L Industrial b <br /> Cable. Tool Dia. of Well ExcAvation <br /> Domestic/private Drilled Dia. of Well Casin �j , <br /> Domestic/public Driven g' l <br /> Gauge�'of Casing % <br /> Irrigation Gravel Pack Depth'-.6f Grout Seal <br /> Cathodic` Protection Rotary Type of Grout <br /> Disposal` Other Other Information <br />' Geophysfcal <br /> . ! Surfate-Seal Installed By: <br />' PUMP INSTALLATION: Contractor [ `' y `2"'�%F-\ <br /> Type of Pump <br /> H.P• <br />` PUMP REPLACEMENT: <br /> / / State Work Done <br />: PUMP .REPAIR: Y State Work Done f <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I I <br /> I hereby agree to comply with all Yaws and regulations of the San Joaquin Local Health District <br /> and the State -�-Californiia--pertiai'nin-g-tom-'r-�ulat-i.ng 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 we1Z and&notify -them before putting the..well,in use. IThe above <br /> information is true to the best of my. knowledge and belief. I WILL C �FO A-GROUT GROUT -PECT,ION <br /> PRIOR TO GRO ING AND FI AL INSPECTION, <br /> SIGNED <br /> `w TITLE <br /> ` c (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION .ACCEPTED BY <br /> ADDITIONAL COMMENTS: A DATE <br /> PHASE II GOUT INSPECTION PHA$:E I/YINAL,INSPECTION ' <br /> INSPECTION BY DATE INSPECTION DATE <br /> ._E-H 1426 <br /> Rev. 1-74 y � j 1177... <br />