Laserfiche WebLink
�101601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ;OFFICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ 7� <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 a 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 /> �- , <br /> JOB ADDRESS/LOCATION �. -� , NSUs TRACT . . <br /> Owner's Name Phone <br /> Addressz"r. �.tJ� City <br /> Contractor's Name ' License e6 13 7 Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR 4;� PUMP REPLACEMENT /7 <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 /> Indus.tr-ial � `. Cb3�e�oo3.-T-- -Dim:of`We1 EScvat�on �' <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 ' ' . Q <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 0-le <br /> Type of Pump '- -t��r�= "�` H.P. =I Q2 <br /> PUMP REPLACEMENT: / / State Work Done •-. . <br /> PUMP .REPAIR: State Work Done P.4,1& �- <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 /> j 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 i rue to-the best.of my-knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION . <br /> PRIOR TO GROt&ING M A FI SPECrION <br />, SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Y" <br />