Laserfiche WebLink
.�.gj SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 70Fi.*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-L/,-)-7 u) <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 /> JOE ADDRESS/LOCATION L,- J <br /> // a2 - CENSUS TRACT <br /> Owner's Name Phone <br /> p -- <br /> Address0 11 J City <br /> Contractor's Name 0- LicenseU <br /> JvQj_<K Phone '" lv 3 <br /> TYPE OF WORK (Check): NEW WELL /T DEEPEN '/-7 RECONDITION /-7 DESTRUCTION j <br /> PUMP INSTALLATION/ / PUMP REPAIR -1-7—PUMP REPLACEMENT /7 <br /> Other Ll —' <br /> DISTANCE TO NEAREST: SEPTIC TANK &MS EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (N <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 16 it <br /> Domestic/public Driven Gauge of Casing /—It-4". <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surf ace Seal Installed ._. .. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP_REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximatd 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-of- my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO GRQUTING, AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE ,��s��'� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIIYINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H <br /> 1426 Rev. 1- 74 r" U75 2M <br />