Laserfiche WebLink
r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTS <br /> FOF�:OFF�SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT. Permit No. Zs- 1/96I?' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-7-7F-1 . <br /> (Complete In Triplicate) r . <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 Joaquin: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. , <br /> JOB ADDRESS/LOCATION els c�� a <br /> CENSUS TRACT ; <br /> Owner's Name Y ' 4 .ca. Phone <br /> Address City . G40 a/ <br /> License Phone ,r-7 6 7b <br />� Contractor s Name - •• <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN-/? PRECONDITION %T DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR PUMP REPLACEMENT �T <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 /> Industrial Cable Tool Dia. of Well. Excavation \`�^ <br /> Domestic/private Drilled Dia.. of Well Casing rvl <br /> Domestic/publicIDr3ven Gauge of Casing <br /> Irrigation 'Gravel Pack Depth of Grout Seal li: <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Y Other Other Information- ' <br /> Geophysical Surface Seal Installed By. <br /> , <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump 4, 4aaduloll H.P. <br /> .. r <br /> PUMP REPLACEMENT: . / / State Work Done . ..L <br /> PUMP '.-REPAIR: IAC/ State Work Done <br /> 4f <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 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..k le e d belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GR UT NG ANDA FINAL INSPE <br /> k <br /> SIGNED • ITLE Baa <br /> s (D P T PLAN ON RSE SIDE <br /> 0 DEP TMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE (J Z <br /> ADDITIONAL CON MEN TS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE Z� <br /> r <br />