Laserfiche WebLink
v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£ tUFFICE USE: t' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 - - <br /> APPLICATION FOR WELT, CONSTRUCTION OR PUMP PERMIT Permit No. 6.16 J9 <br /> 9-16 J9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �6 <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 /> ounty Ordinance No. 1862 and the Rules and Regulations of he San Joaquin Local Health District. <br /> TION U CENSUS TRACT <br /> JOE ADDRESS/LOCA <br /> „Owner's Name . j( .S 01 Phone /f/eJr <br /> City <br /> Address <br /> Contractor's Name �` License7,7 Phone �.. <br /> TYPE OF WORK (Check) : NEW WELL/Lp-D-EEPEN I / RECONDITION /—T DESTRUCTION <br /> PUMP INSTALLATION / I PUMP REPAIR / I PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST:-e. SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE.DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE rs TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial Cable Tool Dia. of Well Excavation / (� <br /> .?-'-Domeatic/private ­4 <br /> Drilled Dia. of Well Casing Cn <br /> Domestic/public 7 N Driven _Gauge of,Caping_ <br /> Irrigation Gravel-Pack Depth of Grout SealD <br /> Cathodic Protection Rotary Type of Grout _ Q' S' . Z -- <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal. Installed BvigLrf <br /> PUMP INSTALLATION: Contractor � '� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /7 State Work Done <br /> -PUMP-q PAIR: /77 State Work Done - _ <br /> E4 S•TRUCTION 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 and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR TING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> .3 ml FOR DEPARTMENT USE ONLY <br /> PHASE I `y/�G <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHAS I GROUT INSPECT ON PHASE TII FINAL INSPE TION <br /> INSPECTION 9Y DATE INSPECTION BY — �DATE <br /> 8 H 1426 Rev. 1-74 1-74 2M <br />