Laserfiche WebLink
- .� � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FDF}"rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 :Wade 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 CENSUS TRACT <br /> 0Owner's Name Phone <br /> Address Cit ' <br /> Y : <br /> Contractor's Name ` m t, License #,15' <br /> dj d Phone -6-3st <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN / CONDITION /_ DESTRUCTION /-f <br /> PUMP INSTALLATION / PUMP REPAIR /7 PUMP REPLACEMENT <br /> 17 <br /> Other / / 1 -- <br /> DISTANCE TO NEAREST: SEPTIC TANK Q R LINES O IT PRIVY',. r z <br /> SEWAGE DISP SAL F ELD I SSPOOL/SEEPAGE P OTHER <br /> PROPERTY LINE - PRIVA�IC WELL PUBLIC DOMESTIC WELL �' <br /> INTENDED USE *-TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> XPAim trial 3 , Cable Tool Dia. of Well Excavation _ _CIS <br /> t Domestic/private :? Drilled <br /> Dia.., of Well Casing t <br /> =Domestic./public -`Driven ¢ Gauge of�Casing� _ ,4 yd <br /> Irrigation Gravel Pack i Depth7,of Grout Sea -- !� <br /> r Cathodic Protection Rotary^ " Type of Grout <br /> Disposal Other Uthek Information v <br /> Geophysical ' Surf eal Insta ed B <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pu Ao=lod <br /> P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP.`.REPAIRS .1 17 'State Work Done <br /> ES1RUCTION OF WELL: Well Diameter Approximate Depth <br /> ` Describe Material and Procedure,-,.- <br /> thereby <br /> rocedure,-Ihereby agree{-to-comply with all .laws and regulations;of the San Joaquin,'Local Health District r <br /> and the State of California `pertaining to or regulating well'construction. Within FIFT-EEN DAYS-: <br /> after completion of my work ona. new,' ell., I_will.furnish the-San' - Joaquin Local Health District' s <br /> WELL ILLERS REPORT of the 'well and notify them before putting the-well in.use.. The above <br /> info t is true to the-best of knowledge and belief. . I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR 10 ING AND A IN I I <br /> SIGNED TITLE C a.- - ,.,.._ <br /> t F PLOT P ON-REVERSE SIDE) <br /> x - FOR"DEPARTMENT. USE,"ONLY <br /> RASE I �� n� - • <br /> EPTED BY '�1 DATE 0 <br /> ADDITIONAL COMMENTS; .— <br /> ' PHAS I GR T INSPECTION ' PHAI/VINAL INSPECTIQNf <br /> INSPECTION BY DATE - ; ` -_.INSPECTION BY 77 <br /> DATE <br /> �,/ <br />' ^E $ 1426 Rev. 1-74 �, �., 4� F , � <br /> 3 _ {. <br /> I-74 2M <br />