Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE.-OFFICE USE: � 160L. E. Hazelton Ave. , Stockton, Calif. - <br /> Telephone: (2Q9) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM .DATE ISSUED Date Issued -�-7 <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 '3oaquinl <br /> County Ordinance No. 1862 and <br /> he Rules and Regulations of. the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION C' CENSUS TRACT <br /> Owner'e Name Phone <br /> 1 <br /> Address SR <br /> City ' <br /> Contractor's Name + <br /> License 0,200 Ef Phone G'O�a�� <br /> TYPE OF WORK (Check): NEW WELL. _& DEEDI <br /> P / RECONTION�/� DESTRUCTION f7PUMP INSTALLATION ; PUMP REPAIR -/-7—PUMP REPLACEMENT /7 ' <br /> r Other j/7 <br /> ' S <br /> DISTANCE TO NEAREST: SEPTIC TANK R,,LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIE:D ! CESSPOOL/SEEPAGE PIT OTHER <br /> f PROPERTY LINE - PR .E7DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED, USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable ' Dia. of Well Excavation p r N <br /> Domestic/private Drille Dia. of Well .Casing`' 9 cc <br /> 't, <br /> Domestic/public Driven Gauge of Casing VC Qc) <br /> Irrigation Gravel a Depth of Grout Se <br /> Cathodic Protection Rotaryr Type of Grout <br /> Disposal Other . Other Information ' ' . <br /> Geophysical Surface Seal Installed B'LL: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. Sick <br /> PUMP REPLACEMENT: / / State Work Done>, <br /> PUMP ruPAIR*.- - /� State'Work DoMe <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material ani. P,rOcedure r <br /> I hereby agree to comply with all laws and ul`ations of the San Joaquin Local Health District <br /> and the State of California pertaining to r l roil acing well"construction. Within FIFTEEN DAYS i <br /> after completion of trey work on a new well, wi.'l1 furnish the San Joaquin..Local Health District a <br /> WELL DRILLERS REPORT of the well and motif before putting.the.:.well. in.use.... .The above <br /> information is true to the-best-of- my knows g. and belief: I`WILL FORA GROUT INSPECTION <br /> PRIOR TOG TING AND A §M& INSPECTION. ; - <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ;�,-. <br /> APPLICATION ACCEPTE] BY - DATE- .,2y <br /> ADDITIONAVCOMMENTS: <br /> (PHASE II GROUT INSPECTION HAS II IN -'INSPECTION j <br /> INSPECTION BY Fly DATE 3 h INSPECTION BY DATE `" f <br /> �. Ael <br /> E`H U20; i-7L t.I7t �u <br />