Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSOFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6787. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITw Permit No. 76-13041 <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 Sac: Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ 3[� ��� T-_ .�.. CENSUS TRACT <br /> Owner's Name Iia Phone <br /> Address - - f-' City ' <br /> Contractor's Name , License U Phone <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN '/-7 RECONDITION /7 DESTRUCTION <br /> UMP INSTALLATION/ / .PUMP REPAIR/-7 PUMP REPLACEMENT /" <br /> Other <br />$ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PiOPERTY LINE -- PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> In �. <br /> dustrial 1 . Cable Tool Dia. of Well Excavation <br /> Domestic/private • Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> t Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPATR: % I State Work Done <br /> DESTRUCTION OF WELL: Well Diameter w Approximate De th <br /> Describe Material and Pr edure e, <br /> '11I S1J <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-o Within. FIFTEEN ,DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Hedlth--District a <br /> WELL DRILLERS REPORT ofjj1the 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 /> PRIOR TO GROUTI G AND A11IFTNAL INSPECTION. <br /> SIGNED TITLE <br /> I�! KDRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY� DATB , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I ECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY 11, DATE INSPECTION BY DATE 5 <br /> � E7. <br /> f <br /> iE R 1426 _Rev, 1-74 =`+,L7� ._-_-• <br />