Laserfiche WebLink
V/ SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> FO h OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> r n APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .6 N3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /a-8-7R <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 Joaqu <br /> County Ordinance .No. 1862 and�the Rules and Regulations .of the San Joaquin Local Health District <br /> Ci-OO V+ Jd/jam CENSUS TRACT _T— <br /> JOB ADDRESSMOCATION D <br /> Phone <br /> Owner's Name <br /> City ' <br /> Address � <br /> Contractor's Name License 7 /Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN J-7 RECONDITION_/ DESTRUCTION /� <br /> PUMP INSTALLATION / / .PUMP REPAIR / PUMP REPLACEMENT 1-7 <br /> Other !/ / ~� <br /> DISTANCE TO NEAREST: SEPTIC TANK -4' SEWER LINES � � PIT PRIVY i <br /> —L <br /> "^-— --SEWAGO DISP -FIELD' f �C OOL/SEEPAGE PIT i - OTHER <br /> PROPERTY LINE - PRIVAT MESTI.C_W.ELL__-PUBLIC DOMESTIC WELL <br /> INTENDED USEa , _,TYPE' 0 LL CONSTRUCTION SPECIFICATIONS <br /> trial <br /> Cable Tool Dia. of Well Excavation_ <br /> =trial <br /> vate� w Drilled _ .-- _ T Dia.of.Well Casing%- f n <br /> Domestic/public . Driven -Gauge-of Casing ' <br /> 1Irrigation It Gravel PackDepth of Grout Seal <br /> S et^' /r Rotary Type of Grout <br /> ! Cathodic Protection y Other Information'/ <br /> Disposal Other <br /> GeophysicalI ' Surface Seal Installed By: <br /> I PUMP INSTALLATION: Contractor <br /> `•�R.P. <br /> Type' of Pump �. <br /> j PUMP REPLACEMENT:' / / IState Work Done <br /> v j <br /> PUMP •.REPAIR: f / / State Work Done <br /> E I Approximate Depth <br /> t•DES•TRUCTION OF WELL: Well Diameter <br /> _l-•^ < ._ �� Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Diatri <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 Distri <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> infprmation A true to the est of my knowledge and belief. I WILL CALL FOR <br /> A'GROUT INSPEC <br /> PRIOR TO GR G D A AL SPECTION. TITLE C <br /> SIGNED (DRAW OT PLAN ON REVERSE SIDE <br /> ( <br /> LqR DEPARTMENT USE ONLY <br /> PHASE I �/� DATE ` <br /> APPLICATION ACCEPTED BYy// -r'r 7 a <br /> t ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE If <br /> GROUT INSPECTION DAT <br /> + INSPECTION BY DATE INSPECTION BY /� —� <br /> " l <br />