Laserfiche WebLink
a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fl•R" OFFICE USE: 1601 E. Hazelton Ave. , <br /> Stockton Calif . <br /> Z-� Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL WELL OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> . bate Issued Z Z <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION `I �,/ l Lf' « CENSUS TRACT <br /> Phone <br /> Owner's Name <br /> �.. �? City <br /> � <br /> Address - � _ <br /> j License ���Q;z4� Phoned �Z <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL / // DEEPEN / I RECOND.ITION.[-Y/. DESTRUCTION /^T � �. <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP©SAL FIELD CESSpO(}L/SEEPAGE PIT OTHER a <br /> PROPERTY LINE - PRIVATE DOMESTIC 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 /> Dome:gati/p <br /> ublic Driven Gauge of Casing <br /> Irrigation 'Gravel Pack � Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout S <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By : <br /> PUMP INSTALLATION: Contractor 141eZrl H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work,Done <br /> PUMP .REPAIR: / <br /> State Work Done <br /> � DES•TRUCTION OF WELL: - We11+Diameter' <br /> Approximate Depth <br /> Describe Material and Procedure <br /> th all laws and regulations of the San Joaquin Local Health District <br /> I hereby agree to comply wi <br /> and the State of Californiapertaining to or regulating well construction. Within FIFTEEN DAYS <br /> n Joaquin- Local Health District a <br /> after completion of if work on a new well, I will furnish the San <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 /> PR10R TO GROUTING AND-A FI�0����PLANON <br /> TITLE Y . <br /> SIGNED <br /> REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE L <br /> APPLICATION."ACCEPTED, BY <br /> ADDITIONAL COMMENTS: - P S I /FINAL ISpECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> �l1v�.7 <br /> b/77 _ 1�1 <br />