Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -FOE OFFICE USE: 1601 E. !Hazelton Ave.,, Stockton, Calif. <br /> Telephone: {209) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM BATE ISSUED Date Issued7, <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Heal.th .District for a pe'r'mit 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 /> 11 <br /> ,TOB ADDRESS/LOCATION F1TRACT <br /> Miner's Name � 11-�_ ��- r •,-.� _ Phone <br /> Address 6— A 192 City <br /> Contractor's Name Licease Phone / <br /> q y-�-Z <br /> -i <br /> TYPE OF WORK (Check): NEW WELL /ZT--MEPEN /_/ RECONDITION/_7 DESTRUCTION /_7 - -•�� <br /> PUMP INSTALLATION /Z7-�7 UMP REPAIR / /—PUMP REPLACEMENT /- <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD iCESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE .DOMESTIC WELL — PUBLIC ;DOMESTIC WELL <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. .of Well Excavation '/ p <br /> c..�mesticf private,. Drilled Dia. of Well Casing 'r �} <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation GraveI-Pack Depth of Grout Seal <br /> Cathodic\Protec.tion c_—R-otary Type '-of Grout . _ (13_ <br /> Disposal . Other Other Information <br /> Geophysical , Surface Seal Installed -By: <br /> POMP INSTALLATION: Contractor <br /> F Type of Pump �. A <br /> BUMP REPLACEMENT: / / State Work Done �r <br /> State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and .Procedure <br />' ,..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 DA <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 GRO IN AND A FINAL INSP ION.. k <br /> SIGNED _ :` - TITLE <br /> (DRAW PLOT PLAN ON REVERSE'SIDE) <br /> `r FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> €_APPLICATION ACCEPTED BY DATE 16:- / Z2 z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY p D;TE -� �� 7OL <br /> 6/7.7 _ 2M <br />