Laserfiche WebLink
,F. <br /> 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT j <br /> FOF�;OFFICE USE: 1601 E. Hazelton Aver., Stockton, Calif. �I <br /> Telephone: (209) 466-6781 to <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 iy 4ir� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <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 worts herein described. This application is made in compliance with San Joaquin <br /> County Ordligance No. 1$9 and the Rules and. Regulations of the San Joaquin Local Health District. <br /> G2srs � ,I <br /> JOB ADDRESS/LOCATION CENSUS TRACT :2013 - 2-t o -Lp � <br /> Owner's Name Phone , 6cif f ! <br /> Address city . -1 <br /> Contractor's Name License # I Phone FJr-_ Vis-?a <br /> i <br /> 4 <br /> TYPE OF WORM (Check): NEW WELL147 DEEPEN j-7 RECONDITION /7 DESTRUCTION 1-7 ji <br /> PUMP INSTALLATION / / PUMP REPAIR '/� PUMP REPLACEMENT /7 <br /> Other /_7 . . . . . . Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> _ ._ SEWAGE DISPOSAL. FIELD CESSPOOL/SEEPAGE -PIT -OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL`-` PUBLIC DOMESTIC-WELL-- -�— <br /> =INTENDED-USE""'"J- .." TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation II <br /> Domestic private--- .- -r..,,Dri11ec1,, , --.. M Dia of We11;Cas.ing <br /> Y Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Pr_otect_i_ on Rotary `. ° Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'By: !►/ '. pv <br /> �I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> -PUMP-,:-REPAIR: / / State Work Done , <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth I� <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 nota€y !them before putting.. the.rwell 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 'AND A FINAL INSPECTION.' �� <br /> SIGNED -_ TITLE i! <br /> {DRAW PLAT PLAN ON REVERSE SIDE �i <br /> .-' FOR DEPARTMENT USE ONLY I' <br /> PHASE I I� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II 'GROUT INSPECTION L*'PHASS III INSPECTI N` <br /> INSPECTION BY DATE INSPECTION BY DATE <br />