Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOF: OFFICE USE: V 3601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781IT Permit.No. 7 L--7 3 p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERM <br /> Date Issued- 3-a- 6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .---- <br /> (Complete in ftiplicate) .", <br /> Application is hereby made to the San Joaquin LocalIlealth llcation istrict fmade inrcompliancea permit twhnSanu3oaquin <br /> and/or install, the. work herein described. This application <br /> County Ordinance o. 1862 and the Rules and Regulations of the San Josqu�n Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> { <br /> Phone .�?6S x/.33 V. <br /> Owner's Name , <br /> city <br /> Address _ <br /> �����p�� <br /> �- License 4/41 i'hori <br /> Contractor's Name <br /> TYPE OF WORM (Check): NEW WELL 17 . -DEEPEN �/7 RECONDITION T DARE IU,CACEOM <br /> ENT <br /> PUMP INSTALLATION / I/ PUMP REPAIR/ PUMP <br /> Other <br /> DISTANCE TO NEAREST:' SEPTIC TANK SEWER <br /> LINES _ PIT PRIVY <br /> SEWAGE DISPOSE-FIELD CESSPOOL/SEEPAGE PIT <br /> _ _ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELT. I CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Toor" Dia. of Well Excavation <br /> Domestic/private Drilled =' Dia. of Well Casing � ►� <br /> f Domestic/public -� --' -Driven- Gauge-of-Casing- <br /> Gravel Pack, Depth of Grout Seal <br /> Irrigation <br /> i Type_of Grout <br /> Cathodic Protection Otheryx_T k^ w Other Information <br /> —Disposal Disposal ' �m —' Surface Seal Installed B <br /> f _Geophysical <br /> PUMP INSTALMIONf-7c6nCracior <br /> E Type of Pump �• H,P. <br /> ► e Work Don � —z <br /> PUMP REPLACEMENT: Stat <br /> PUMP ,REPAIR: / / State Work.Done <br /> � 9 <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 /> 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 DistDistrict <br /> WELL DRILLERS REPORT of the well and notify them before putting-the..well. in.use.... . <br /> information is true to the-best of—my—knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> [ PRIOR TO GROUT AN A FjW INSPECT TITLE - <br /> SIGNED <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I DATE <br /> f�l�v <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHAS I F �L�IN <br /> PHASE II GROUT I PECTION INSPECTION BY //--7�INSPECTION BY DATE -r . 4Z2M <br />