Laserfiche WebLink
" M SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-30141 <br /> 1 <br /> THIS PERMIT EXPIRES l 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 instal, 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 ���•, ��-� CENSUS TRACT <br /> Owner's Name ` . Phone $` <br /> Address '/ City - <br /> Contractor's Name ; ` License ��Phone`4,7? <br /> TYPE OF WORK (Check) : NEW WELL /F,7- DEEPEN /7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR I-7 PUMP REPLACEMENT 17 <br /> Other /-7 . . . . . <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 /> iE7-Domestic/private Drilled Dia. of Well Casing,- <br /> Domestic./public <br /> asing,-Domestic./public Driven Gauge of Casing <br /> Irrigatioti: ' r Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout J , <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT /7 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 CALL FOR A 'GROUT INSPECTION <br /> PRIOR TOG UTING AND NALINSP O . <br /> SIGNED , ? -� ,L TITLE r. <br /> {DRAW PLAW ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHA IN INSPECTIO <br /> INSPECTION BY DATE � INSPECTION BY DATE <br /> V v 111.1 IG <br />