Laserfiche WebLink
r <br /> Awl <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P <br /> 0 FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> y Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -; ;0 <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 fox a permit to construct t <br /> and/or'- install the work herein described. This application is made in compliance with San Joaquin <br /> and Regulations of the Sari Joaquin Local Health District. <br /> County Ordinance No. 1'862 and the Rules <br /> -�' CENSUS TRACT <br /> JOB ADDRESS/LOCATIONig! <br /> Owner's Name L Phone, <br /> 1I ,6 City /iia ON <br /> Address <br /> Contractor Name License 1 hone <br /> 4. <br /> r <br /> TYPE OF WORK (Check): NEW-WELL /� DEEPE�I_T- RECONDITION/� DESTRUCTION /^T <br /> PUMP INSTALLATION / / .PUMP REPAIR PUMP REPLACEML�NT �"T <br /> Other <br /> I <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 r-� Cable Tool Dia. of Well Excavton <br /> �p Domestic/private Grilled . Dia. of Well Casing <br /> Domestic/public Driven t Gauge of Casing <br /> s 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 By: <br /> { <br /> PUMP INSTALLATION% Contractor <br /> Type .of Pump H.P. <br /> t _ s <br /> ` PUMP REPLACEMENT: / / State .Work Done <br /> PUMP "R, <br /> bd State Work Done <br /> 'k DES1RUCTION 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 /> ll'-construction. Within FIFTEEN DAYS <br /> and the State of California pertaining to or regulating we <br /> after completion of my work on anew well, I will furnish the San Joaquin Local Health District a <br /> s 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 owled an d elief. I WILL CALL FOR A-GROUT INSPECTION <br /> PRIOR TOrGR0QTNG 'AND A FINAL INSPE ON. <br /> SIGNED l TLE <br /> ' LOT L ON RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - DA <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHAS IO <br /> AL INSPECT <br /> PRASE II GROUT INSPECTION` DATE <br /> INSPECTION BY DATE - - INSPECTION BY <br /> a U ILIA '0­ 7-74 <br />