Laserfiche WebLink
IPW <br /> 3 SAN JOAQUIN LOCAL HEALTH DISTRICT t.FOF OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. _ x <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� -/moi„ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7 7 <br /> (Complete In Triplicate) <br /> Application is $ereby 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 vZ �7 YrC(�c{.OLy� L,4ii� C �L�9Canr C�xiG CENSUS 'TRACT <br /> E <br /> Owner's Name /r'r9v,`s G�/icG,rsr+�l Phone t"6 <br /> Address <br /> City C"S'G4coN, {�u�F <br /> Contractor's N me License <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION / / DESTRUCTION /_ <br /> `.- <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> E 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 <br /> 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 /> 's 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 <br /> H.P. . . . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> DESTRUCTION 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 of my knowledge and belief. I WILL L FOR A GROUT INSPECTION <br /> PRIOR TO G . UTING A FINAL INSPECTION. <br /> SIGNED TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DAT �—' / ' <br /> ADDITIONAL COMMENTS: <br /> �r <br /> PHASE II GROUT INSPECTION PHA S INAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE 7 7 <br /> E H 1426 <br /> Rev. 7 1177 _ 2M <br /> . 1- 4 <br />