Laserfiche WebLink
CV11 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made t' the Sun Joaquin Local Health District for a permit to construct j <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 /i!? 5 fL 26 I? 9-IF T '? 11l <br /> CENSUS TRACT �^ <br /> Owner's Name PhoneY4 <br /> i <br /> Address City <br /> Contractor's Name License # 7j 604 Phone - <br /> l TYPE OF WORK (Check): NEW WELL Imo, DEEPEN '/? RECONDITION f-7 DESTRUCTION f-7 <br /> PUMP INSTALLATION 1_7 PUMP REPAIR 1-7PUMP REPLACEMENT 17 <br /> k 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 Q <br /> } Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing j Z <br /> Domestic/public I Driven Gauge of Casing <br /> Iiiigation ,t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> f Disposal' , i Other Other .Information <br /> Geophysical. I Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT- / / State Work Done . <br /> PUMP .REPAIR: / / State Work Done <br /> ` DES•TRUCTION OF WELL: .Well Approximate Diameter Pp 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 thewelland notify them before putting the..we11 in.use... ,The-above <br /> linformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO_GRQUTING ANDAFINAL INSPECTION. _ <br /> SIGNED TITLE u�-Li <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I 7. <br /> APPLICATION ACCEPTED BY DATE 1I Z 7� <br /> (ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION' PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATEINSPECTION BY DATE <br /> F U ILIA <br />