Laserfiche WebLink
co <br /> " SAN JOAQUIN LOCAL- ,HEALTH DISTRICT <br /> FUE;OFFICE USE:. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:p (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 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 /> JOB ADDRESS/LOCATION //C �]p�, ® 0 ,P aG-4 f 1 CENSUS TRACT <br /> Owner's Name 42 r✓_,"1,02y t5 a-C, Phone , <br /> Address City '-'- <br /> Contractor's <br /> ity <br /> Contractor's Name License # ��:?�J Phone x'7671 <br /> TYPE OF WORK (Check): NEW WELL -1 7 DEEPEN '/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR REPLACEMENT 17 <br /> Other <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 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial, Cable -Tool Dia. of Well-Excavation <br /> Domestic/private Drilled Dia. of Well Casing- <br /> Domestic/public Driven Gauge of Casing <br /> C� Irrigation . Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ..� - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor Q' ✓ e.�� <br /> Type of PumpR.P. <br /> 30 <br /> PUMP REPLACEMENT: / / State'Work Done <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 notify them before putting..the..well in.use.... .The above <br /> information is true to.the•best ,of my..knowledge belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING .D A FINAL. INSPECTI N. <br /> SIGNED 0� y ITLE <br /> (D W LOT PLAN ON RE RSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I ,�'" <br /> APPLICATION' ACCEPTED BY DATE v / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPEC'T'ION BY DATE INSPECTION BY DATE <br />