Laserfiche WebLink
SCJ SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> FORf'OFFICE USE: 160.1 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'Distridti" ' <br /> JOB ADDRESS/LOCATION q ? Lqxf CENSUS'TRACT <br /> Owner°s Name Phone <br /> Address " M S �,_.. = Cit .. )y <br /> y �� <br /> Contractor's Name �So Ar - __ License # a 7901 o one Ph3 <br /> .�t 0 Z <br /> TYPE OF WORK (Check):..i NEW WELL /- DEEPEN /_7 RECONDITION /_7 DESTRUCTION /-7 , 1{ <br /> i <br /> PUMP INSTALLATION / / PUMP REPAIR _0_j PUM -\REP' ACEMENT 17 <br /> Other /J a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY . r" <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 i <br /> Domestic/private Drilled Dia hof Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack : 'Depth of Grout Seal <br /> Cathodic Protectioii Rotary Type;,iof .Grout <br /> Disposal 1 Other Other Information ` <br /> Geophysical = Surface Seal Installed By: <br /> PUMP INSTALLATION: Contt'actor � - <br /> Type f of Pump <br /> PUMP REPLACEMENT: /_-/ Stiate Work Done 2 f " <br /> PUMP :REPAIR: V _-,State .Work Done"' <br /> ES;TRUCTION OF WELL: Well-,Diameter Approximate Depth ' <br /> Describe Material and Procedure d' <br /> T hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Californial.pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my raork on anew well, I will furnish the Sail Joaquin Local Realth•'District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe- well in.use.. The above <br /> information.is -true -to the.best-of my-knowledge- ai d"`belii4-.--I""WILL-BL FAL "A GROUT INSPECTION <br /> PRIOR' TO GROMNCs..AND F NAL-INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY .�+.� .. DATE <br /> ~E H 1426 Rev, 1--74 v_ .., s•- ... �. � � ._ _..- <br /> 1-74 2M ,� <br />