Laserfiche WebLink
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.0 BICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:' (209) 4664781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 70 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date, Issued /V <br /> (Complete In Triplicate) <br /> Application is heieby 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 a R CENSUS TRACT -- <br /> Owner's Name r-t Phone - <br /> Address <br /> hone "Address 0, ?� om City <br /> Contractor's Nam License V�ynhone :L-• � � <br /> f <br /> TYPE OF WORK (Check): NEW WELL/_7 TADEEPEN "/? RECONDITION /7 DESTRUCTION J 7 J <br /> PUMP INSLLATION PUMP REPAIR "/_7 PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (,J <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 /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' <br /> - Disposal Other Other Information <br /> Geophysical. f Surface Seal Instal3ed 'By: <br /> PUMP INSTALLATION; ry` Contractor14 fe:,�(S�� <br /> Type .of Pump zsai- H.P. <br /> PUMP REPLACEMENT: . f / State Work Done. st -C-4411026' <br /> PUMP .REPAIR: / / State Work Done <br /> DES-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'construetion. 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 iiotif_y--twhem before putting the..well. in.use.... The above <br /> information is true to the-best f my.. �swledge a belief I WILL CALL "FOR A "GROUT INSPECTION <br /> PRIOR TO GR UTING AND A FINAL PCT �N _ n <br /> .'SIGNED(S TLE O'ay- <br /> DRAW PLOT PLAN ON RSE; SIDE <br /> R D I'ARTMENT USE ONLY <br /> .PHASE I � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III' FINAL INSPECTION <br /> INSPECTION BY DATE.. INSPECTION BY DATE <br /> R H 1426 RP-v_ 1-74 r. . 2M <br />