Laserfiche WebLink
' SAN JOAQUIN LOCAL HEALTH DISTRICT V& ,A <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � 1 + <br /> Telephone: 20 ) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 install the work herein described. This application is .made in compliance with San Joaqu <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION f5`3a CENSUS TRACT <br /> �� Phone - <br /> Owner's Name <br /> �. City <br /> Address <br /> � License p2^� Q 'Phone�XF2,4o? <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL j/ DEEPEN/_7 RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> 1 Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> "k SEWAGE DISPOSAL FIELD :` . •CESSPOOL/SEEPAGE PIT /�' OTHER <br /> S-T-I-C WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC-WELL-'_ <br /> -.UCTION~SPECIFICATIONS . <br /> INTENDED USE ,�__ TYPE OF WELL �� ` ' <br /> Industrial Cable Tool ' Dia. of Well Excavation <br /> Domestic/private <br /> 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 Surface Seal Installed B <br /> 4 - <br /> PUMP INSTALLATION:-, Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done . , <br /> PUMP -.REPAIR: / / State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquiri"Local _Health Distric <br /> k and the State of California pertaining to or regulating well 'construction.' Within FIFTEEN DAY <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distric <br /> k WELL DRILLERS REPORT of the well and notify them before putting_ th e well: in use.. The above ' <br /> information is true to. the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECT IO <br /> PRIOR TO GROUTING A NAL S TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPAR MENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: ' pHA III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> 1/77 _ 2M <br />