Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ;7 <br /> S CIO nl. C.z�,Q� � (Complete In Triplicate) 02 s_�Dp�p3 <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 Jopquin ` <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. j <br /> i <br /> JOB ADDRESS/LOCATION CENSUS TRACT " <br /> Owner's Name / Phone <br /> Address ,� �- U F' C� Ar- 6".GjJ/Q'/7 City t <br /> Contractor's Name{. i 7`� Sed ` ; � Phone _ �-1 `1��/ <br /> TYPE OFYWORK (Check) : NEW WELL/D—EEPEN. / / RECONDITION /—/_ DESTRUCTION <br /> AL /?'' <br /> PUMP INSTALLATION /i?� UMP REPAIR / / 'PUMP REPLACEMENT /- <br /> � rF <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE Z;, cz, PIT PRIVY „. <br /> SEWAGE DISVUAAL CCMSpOpL/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 /> Af!--rlomestic/private Drilled Dia. of Well Casingr <br /> Domestic/public Driven Gauge of Casing fn <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ` <br /> DisposalOther Other Information <br /> Geophysical - <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION; <br /> Contractor r -i p <br /> Type of Pump H.P. _ <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP —I <br /> .REPAI �...�_- - .� /�/State--Work-Done <br />)ES,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure j <br /> L 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 /> TELL DRILLERS REPORT of the well and notify them before putting the. well in use. The above <br /> Lnformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> iIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br />'RASE I FOR DEPARTMENT USE ONLY <br /> LPPLICATION ACCEPTED BY DATE <br />►DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTANIvPHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 uptr_ 7_7i, <br /> ll°1 1777 �u <br />