Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -TOT:'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) --4,6-66781 <br /> APPLICATION <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , •,y <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. made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulatio s of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCAT. N &4c� CENSUS TRACT <br /> c <br /> Owner'r�$ atme� Phone <br /> Address -7 City a <br /> Contractor's Name .� ' <br /> License #�(�)j 73 Phone L- <br /> TYPE OF WORK; e-- : ..NEW WELL -/? DEEPEN -1/? RECONDITION f_._DESTRUCTION_/_----.� <br /> _._-.,,.=•-�----�---•-�-"'�i'UMP-IN�TALT.�;�ON � SUMP <br /> REPAIR -77 PUMP REPLACEMENT - <br /> Other <br /> } f} <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERiLINES PIT PRIVY <br /> �~- SEWAGE DISPOSAL FIELD C�SSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY INE - PRI VA MEST @)WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ` 1 `Y t �'�{ CONSTRUCTION SPECIFICATIONS �\ <br /> Industrial Cable T6o . IDia. of-Well Excavation <br /> Domestic/private i Drilled"' I bia. A Well Casing <br /> Domestic/public I Driven !"' bauge o Casing <br /> Irrigation �_ Gravel Pac ''�' Depth o R Grout Seal <br /> Cathodic Protection Rotary € '- Type,o£,-Grout <br /> Disposal �_ Other . _'r:j i w_Gther"-Information ' <br /> Geophysical . I Surface Seal Installed 'B <br /> PUMP INSTALLATION Contract r <br /> E Type of ump H.P. . <br /> r <br /> PUMP--REPLACEMENT. <br /> AF <br /> PUMPIREPAIR-: / / Stale Work Done <br />' RES;TRUCTION OF WELL: Well Diai be ter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with a 'l 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 one new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe .well. in.use... .The above <br /> information is true -the best o my.-knowledge and .belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING -AWA F.4NAI I CT ION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPART 'SE ONLY <br /> PHASE I Al � <br /> APPLICATION ACCEPTED BY �" - DATE 7"-2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FoINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 'E R IA2& Roti_ 1_7G - 1./7f ou <br />