Laserfiche WebLink
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 No. 76 lflV r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued g-S 7G7L <br /> (Complete In Triplicate) <br /> Application is hereby made toithe 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 Joaquini <br /> County Ordinance No:. 1862 and the Rules and Regulations of the San Joaquin .Local Health District. 1 <br /> r <br /> JOB ADDRESS/LOCATION ENSUS TRACT <br /> Owner's-Nam _ .� - <br /> Phone , <br /> 4 City' <br /> Address <br /> Contractor's Name <br /> License # Phone - <br /> TYPE- OF-WORK (Check) NEWWELL-�/7 _DEEPEN�/ (�-VRECONDITION�/_ f7=- <br /> PUMP <br /> = <br /> PUMP INSTALLATION /�I PUMP REPAIR /7 PUMP.'.REPLACEMENT 17 <br /> ,y <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC..TANK re-6 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL-FIELD CESSPOOL/SEEPAGEPIT OTHER \ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELT. PUBLICSDOMESTIC WELL \q <br /> INTENDED USE TYPE OF WELL .� � fr. CONSTRUCTION. SPECIFICATIONS <br /> Industrial _X_, Cable Toole, Dia.'o£ Well Excavation <br /> Domestic/private Drilled i ,Dia;`of Well Casing " + <br /> Domestic/public s Driven �..`Gauge_o€ Casing <br /> r �( Irrigation ;. GraveliPack_.�J.f Depth-of- Grout Seal . <br /> Cathodic Protection rs Rotary I--Type of Grout <br /> Disposal. =u" Other Other Information <br /> Z, Geophysical Surface Seal Installed 'B <br /> PUS' INSTALLATION:., "Contractor <br /> ' <br /> T , Type .of Pump H.P. <br /> h <br /> PUMP REPLACEMENT: `j w/-- State Work"Done \ <br /> State Work Done f..:. _. . . : <br /> PUMP '.REPAIR: hT .- - -- - <br /> �'.. #_ .. ...�.�--++r..2..nwe�•aR. I �y�rs 43 ..yYt,r- l �'-{ " <br /> DESzTRUCTION OF 'WELL: Well Diameter - Approximate Depth <br /> Describe Material and ProcedureW <br /> I hereby agree to 'comply with all laws and regulations of the San Joaquin Local. Health District <br /> and the State of California.pertainiug 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 CALLIFOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. 1 <br /> k SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE3i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE � 7 <br /> APPLICATION ACCEPTED BY _.1C <br /> ( ADDITIONAL COMMENTS: t F <br /> t PHASE II G ; NS ION P II INAL INSPECTI N <br /> i INSPECTION BY DATE INSPECTION BY DATE <br /> V U ILIA Do 7_7& :b" � <br />