Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TO-B4OFFICE USE: 1601 E. ,Haxelton Ave. , Stockton, Calif. % } <br /> Telephone: (209) 466-6781 I <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-(O/) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application id 'hereby11 mai a to the San Joaquin Local 11calth 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' Na,. -1862 and the Rules and Regulations of the Saar Joaquin Local Health District'. <br /> JOB ADDRESS AOCATION . /� tC, CENSUS TRACT <br /> Owner's Name Phone <br /> i <br /> Address -L c �3 ... �3 u``." � . S ��5� City ' ' <br /> Contractor's NameLicense Phoned <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN /7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR-/ PUMP REPLACEMENT <br /> Other <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 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 <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: . Y / / - State Work Done - ` <br /> PUMP 'REPAIR: / / State Work Done <br /> tiES;TRUCTION.OF WELL: _,..,:Well Diameter Approximate Depth <br /> E Describe Material and Procedure <br /> P <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 /> PRIOR TO GROUTING 'AND A FINAL INSPECTION. ! <br /> SIGNED24, <br /> TITLE 0, tJ <br /> (DEAIAT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I E <br /> APPLICATION ACCEPTED BY . DATE ' ��� <br /> ADDITIONAL COMMENTS: <br /> i PHASE If GROUT I SPNCTIff PHASE, III FINAL INSPECTION } <br /> j INSPECTION BY 1 ATE INSPECTION BY 4TM D. DATE07-11-7G f� <br /> �r f <br /> E R 1426 Rav_ 1-74 -- <br />