Laserfiche WebLink
SAN JOAQUIN LOCALHEALTH DISTRICT <br /> t <br /> FOR E: <br /> OFFICE US • 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 7,7-/-j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued *47 <br /> 4 <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 R134les and Regul ons of the San Joaquin Local Health District. <br /> JOB ADDRESS/ ION � CENSUS TRACT 1 <br /> Owner's Name .iLrePhone 4 ,--) .3 <br /> Address Ci <br /> Contractor's Name License � Phone`V&0& <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY y J <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATEDOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> -Industrial Cable Tool. Dia, of Well Excavation � . <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven, Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. r <br /> PUMP REPLACEMENT: / / State Work Done r, 17 <br /> PUMP '.REPAIR: State Work Done <br /> c <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' istrlct <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 4 <br /> information is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION' <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED, TITLE „ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO -DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE d; <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY � DATE <br /> r 1177 _ 2M E <br />