Laserfiche WebLink
C64 f'a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR. FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75__ SV ; <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED Date Issued -,- 7S� <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 a .-reg ' CENSUS TRACT <br /> Owner's Name X-i Phone <br /> Address X !�QCity _ <br /> V <br /> Contractor's Name . <br /> License # �� 7� Phone , <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/- RECONDITION /� DESTRUCTION /7 <br /> PUMP INSTALLATION '/_/ PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL--,-- <br /> INTENDED <br /> ELL INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> & Irrigation Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection Rotary ;Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> F <br /> PUMP ,REPAIR: State Work Done Zs . ^ � <br /> DE&TRUCTION 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 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 owledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO OUTING AND A _SIgAL INSPECT <br /> SIGNEDTITLE <br /> RAWLOT PLAN ON VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Cv DATE l 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN CTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY C / DATE <br /> R R 1426 nom„ i_fi 1./7t 9M <br />