Laserfiche WebLink
_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE;'OFFICE USE: 1601 E. Hazelton.Ave. , ' Stockton, Calif. <br /> Telephone: ., (209) '466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.74L�iGd <br /> THIS PERMIT EXPIRES 1 YEAR FRdM DATE ISSUED Date Issued 7�5�7�0: <br /> (Complete In.Triplicat.e). <br /> Application -is hereby made =to the Son Joaquin Loce1 Health District for a, permit to 'construct <br /> and/or instal: the work herein described: This applicatiasi is made in,,r mptlianc with San Joaqui: <br /> F <br /> County, Ordinance "No: ' 1662 and the Rules and Regulations of .the Salt :Joaquin Local,.-Health District. <br /> JOB ADDRESS/LOCATION f ,CENSUS TRACT s <br /> Owner''a Name <br /> Address (9 <br /> Cita <br /> - � <br /> Contractor's Name <br /> icense 4j Phone�. <br /> TYPE OF WORK (Check): NEW,WELL. LZ7--DEEPEN '17 RECONDITION /7 DESTRUCTION /77 <br /> PUMP INSTALLATION ,C/ PUMP REPAIR-/? 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 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Z---Gable Tool Dia. of Well Excavationf <br /> _ -Mmestic/private . Drilled Dia. of Well. Casing , � <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation... Gravel Pack Depth- of Grout Seal. ' <br /> ' Cathodic Protection Rotary Type of Grout Gf <br /> Disposal Other Other Information ._ <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: -Contractor v <br /> Type -of Pump H.P. <br /> PUMP REPLACEMENT: .:, State Work Done - <br /> PUMP ,,REPAIR: <br /> onePUMP ,,REPAIR: / J State Work Done <br /> F � F <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 FIFTEENDAYS <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°uae.. .'The above <br /> .information is true- to- the-best of My.-knowledge and belief. I WILL CALL FOR�AIGRQUT. INSPECTION ' <br /> (PRIOR TO G TI AND A "FINAL' IN ION, • <br /> SIGNED tTITLE ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY i <br /> ,DATE `m'� - <br /> i ADDITIONAL COMNENTS: <br /> PHASE II GROUT .INSPIECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY ,C> DATE 74 INSPECTION-BY DATE S-/ ; <br /> E It 1426-' Rev: 1. 74 r G/75 .2M <br />