Laserfiche WebLink
r � 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 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued � 7S� i <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct j <br /> and/or install the work herein described. This appli-cation' is made in compliance with San Joaquin: <br /> County Ordinance No. 1862 th Rules }and Regulations of he San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION t CENSUS TRACT <br /> Owner's Name �� Phone <br /> �� lS _3 <br /> Address �✓�C�. it <br /> Contractor's Name ' s License Phone �� / <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION / / DESTRUCTION /_7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. PIT PRIVY <br /> SEWAGE DISPOS L FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ;' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �T <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 ,S <br /> Cathodic Protection _ Rotary Type of Grout t19 14 0� <br /> Disposal Other Other Information <br /> Geophysical _ Surface Seal Installed iffy: 1,da d <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> � I <br /> PUMP REPLACEMENT: / / State Work DoneI <br /> Y PUMPREPAIR: / / State -Work Done <br /> DES-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 ,P true to the best of my knowledge and, belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO W <br /> OGTING AND L INS .ECT IUN. <br /> SIGN TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F X DEPARTMEW USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ?117(? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE J;I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -J <br /> Emco <br />