Laserfiche WebLink
SAN .JOAQUIN' LOCAL`IHEALTH DISTRICT <br /> reOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 }o <br /> 4 <br /> 111 ;. 5` <br /> i THIS PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED Date Issued /p-18;��6 <br /> v (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 Regulations -of the San ,Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / ' <br /> � t � CENSUS TRACT <br /> Owner's Namev r.L v Phone <br /> i Address / _ _, City <br /> Contractor's Name . K License # �p Phone <br /> TYPE OF WORK (Check):.--,.NEW-WELL ION-/?DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR f? PUMP REPLACEMENT /7 <br /> Other, /-7 <br /> i' <br /> i DISTANCE TO NEAREST: SEPTIC'rTANK SEWER LINES PTT PRIVY <br /> SEWAGE-DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OFWELL , +` CONSTRUCTION SPECIFICATIONS v <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private R Drilled Dia. of Well Casing <br /> Domestic/public Driven i Gauge of Casing <br /> Irrigation Gravel Pack " 'Depth: of Grout Seal <br /> Cathodic Protection Rotary �" F -Typelof Grout '�° ,1 <br /> Disposal OtherOther Itxformation <br /> Geophysicalp}Y Surface Seal Installed By, <br /> INSTALLATION: Contract <br /> Aw <br /> PUMP INS V F <br /> or -242s <br /> c1 <br /> ' Type of Pump <br /> H.P. <br /> - <br /> PUMP REPLACEMENT:- / I State Work Done' _ <br /> "PUMP '.REPAIR: .�. - ' �— - <br /> _.. � /��'State-Wark'Done <br /> ES'TRUCTION OF WELL: We 11 Diameter <br /> ' 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 TO GROUTING ANDA FINAL-- INSPECTION, <br /> SIGNED t TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I ,., \ '" ' } FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE l7 <br /> ADDITIONAL COMMENDS; <br /> N'- PHASE II GROUT INSPECTION l <br /> 'cis, PHAS III F AL, INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 11 E H 1426 i'`' Rev. 1-74 1-74 2M <br />