Laserfiche WebLink
_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .15 /v <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7Z <br /> (Complete In Triplicate) <br /> )plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> id/or install the work herein described. This application is made in compliance with San Joaquin <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> )B ADDRESS/LOCATION �� t ;LC"-gym e` CENSUS TRACT <br /> wner's Name { Phone <br /> ddress City <br /> )ntractor's Name C p� .�..; s /,* y License # ;_21✓d/3Phone Ja/ <br /> tPE OF WORK (Check) : -NEW WELL / DEEPEN /_/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> [STANCE 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 p <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 6 <br /> Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal L <br /> Cathodic Protection Rotary Type of Grout <br /> —Disposal Other Other Information <br /> _Geophysical Surface Seal Installe B r' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> UMP .REPAIR: / / state Work Done <br /> - ,S"TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> T hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd 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 /> nformation is true to the best of my knowledge and belief. I WILL FOR A GR T INSPECTION <br /> y_RIOR TO GRO T G AND A FINALI PECTION. <br /> SIGNED v _ p+t TITLE l `� <br /> JDRAW PTbT PLAN 'ON REVERSE SIDVO <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 'PPLICATION ACCEPTED BY DATE As -7,Z <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE , <br /> 3/76 2M <br />