Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br />` FO&.OFF CE USE.: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _.+ i Telephone: (209) 466-6781 5' <br /> o APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z_1 2ls� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 1b <br /> M (Complete In. Triplicate) <br /> Application is hereby made tol�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 andIithe Rules and Regulations of: the San 'Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION '� CENSUS TRACT <br /> Owner's Name YI Phone <br /> Address / cr City <br /> Contractor's Name - License // `Phone •� <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN "/-7 RECONDITION C7 DESTRUCTION /7 <br /> PUMP INSTALLATION '/ / PUMP REPAIR/W PUMP REPLACEMENT /7 <br /> Other / / . . . . . . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DfISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Eta <br /> PROPERTi LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL �} <br /> INTENDED, USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation X11 <br /> Domestic/private -1 Drilled Dia. of Well Casing <br /> Domestic/public t Driven Gauge of Casing C� <br /> y_ Irrigation ;G Gravel Pack Depth of Grout Seal <br /> Cathodic Protec.4on !M Rotary Type of Grout ' <br /> Disposal :I Other Other Information " <br /> Geophysics] Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor ,f l.rsr <br /> Type of Pump �" '. . �` A.P. � ZL <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP '.REPAIR: 27 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, -1 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-besi.of- knowledged belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TQ-GRQdTING AND A FINAL ZNSP I c <br /> SIGNED`'1.� ,TITLE <br /> / ADPW PL OT`PLAN ON V PRE SIDE <br /> FOR DEPARTMENT ME ONLY <br /> PRASE I bi <br /> APPLICATION' ACCEPTED BY DATE - � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE i <br />