Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> -TR"OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.•7.7. Lj {p <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 � � �' �ICENSUS TRACT ' <br /> Owner's Name Phone 3 6 J7- �-Q b� <br /> Address '� Y � -t-� City r <br /> Contractor's Name License PhonJ. ,�J.. <br /> i <br /> TYPE OF WORK (Check) ; NEW WELL /�/ DEEPEN/_/ RECONDITION /.° / DESTRUCTION /_ <br /> !PUMP: INSTALLATION / / PUMP REPAIR )5� � PUMP REPLACEMENT /7 <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 .STYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCabl� Too1 . Dia. of Well_ENcavation ^1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing N <br /> Irrigation i Gravel Pack ► ,,Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal r Other Other Information <br /> GeophysicaliSurface Seal Installed By: <br /> PUMP INSTALLATION: Contractor '' v <br /> Type' of Pump r H.P. 7 <br /> PUMP REPLACEMENT: J / State Work Done ; <br /> Q l <br /> PUMP .REPAIR: 'State Work Done <br /> ,r / • t <br /> DESTRUCTION OF WELL: We11'..Diameter l 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_w.ell._and .notify„,them before.putting the well. in.use. The above <br /> information ,ip true to the best of knowledge and belief. I WILL CALL FOR A GROUT INSPECTION i <br /> PRIOR TO G IN AND NAL INS CTION. <br /> SIGNED TITLE <br /> DRAW Ph T PLAN ON REVERSE SIRE) I: ` <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> r� I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,1,,�/'f� A44 DATE ? <br /> F <br /> E H 1426 Rev l-7_4.. 3/76 2M <br />