Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFs;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,5-- <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sats 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 Rule and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCAQ ` <br /> CENSUS TRACT <br /> Owner's Nam -� P �7 <br /> Address 9 r <br /> City <br /> Contractor'a Name 1 ,� License �c "373 Phone4— 99 <br /> TYPE`OF WORK Check). NEW-WELL . DEEPEN RECONDITION /-7 DESTRUCTION J _ <br /> PUMP INSTALLATION '/ I PUMP REPAIR -/-7 PUMP REPLACEMENT /7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - PIT PRIVY <br /> J' SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL r <br /> .INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI S <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 I <br /> Disposal Other , Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: / / State Work Done <br /> I <br /> PUMP REPAIR: /F/ State Work Done - -_ <br /> DESTRUCTION OF WELL: Well Diameter / Approximate D h t <br /> c Mater 1 and P�roced4re - „1�v y <br /> I <br /> I hereby agree to comply with all laws and regulations of the San Y6aquin 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 anew 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 is true to the.best.of- my..knowledge and belief. I WILL CALL FOR A GROUT INSPEC ION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> {DRAW PLOT PLAN ON REVERSE SIDE � <br /> FOR DEPARTMENT USE ONLY <br /> PHASE T <br /> APPLICATION ACCEPTED BY DATE Z-� ! / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE- III/FINAL INSPECTT N <br /> INSPECTION BY DATE INSPECTION BY G, DATE <br /> -� - <br /> oil <br /> J <br /> � i <br />