Laserfiche WebLink
SAN JOAQUIN LOCAL HEAD DISTRICT <br /> FOR;OFFICE USE: 1601 E. Hazelton Ave. , Stockton,. Calif. y 11 J' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z4- LZ:fV , <br /> THIS PERMIT EXPIRES I YEAR FROM DATE 'ISSUEDDate Issued���9 76 <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 Ordinanc N 186.2 .and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB�D� ��� <br /> REss/L�CATI•N o ,`c S CENSUS: TRACT <br /> Owner's Name Phone <br /> Address tp 0200 <br /> City ' <br /> Contractor's Name <br /> License , Phan <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN 'J7 RECONDITION /_-7 DESTRUCTION / ' <br /> PUMP INST CATION / PUMP REPAIR /� PUMP REPLACEMENT 17 1' <br /> Other <br /> • _ i <br /> DISTANCE TO NEAREST: SEPTIC TANK 1�n SEWER LINES Q PIT PRIVY �- <br /> SEWAGE DISPO" FIELD �"` GOOOPOOL/SEEPAGE PIT �MESTICI <br /> HER - - <br /> PROPERTY LIN PRIVATE DOMESTIC WELL Saf`PUBLI WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Q � <br /> Domestic/private _ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing C� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection yRotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B : �. <br /> PUMP INSTALLATION: r <br /> Contractor /� .1 . <br /> Type of Pump n - H.P. <br /> PUMP REPLACEMENT E7 State Work Done <br /> .. F <br /> PUMP .REPAIR: / / State Work Dons <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 GROAT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTIO . <br /> SIGNEDt <br /> (D LOT JPLAN 09 'VERSE SIDE <br /> FOR 'PART T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE rT� <br /> ADDITIONAL COMMENTS: rAIA IS <br /> PHASE II GROUT INSPECTION v PHAS III INAL INS C <br /> INSPECTION BY DATE - INSPECTION BY DATE J <br />