Laserfiche WebLink
60.� to C r'��/` SAN JOAQUIN LOCA:'HEALTH DISTRICT <br /> FOA+OMCE USE: 1601 E. Hazelton Ave:. , Stockton, Calif. <br /> Telephone: '(209) 4664781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplitate) V-,.., <br /> Application is hereby made to the San Joaquin Local Health District for a permit to coaetruct <br /> and/or install the work_hereiu 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 [,LSG q CENSUS TRACT <br /> Owner's Name ' ) .__1j a n i ki ar � Phone <br /> Address City V c�CT" a <br /> Contractor's Name 144,0 a, � ' .• License $ 1��one <br /> - I <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN -/_7 RECONDITION /_7 DESTRUCTION /_7 <br /> ' PUMP INSTALLATION / / PUMP REPAIR 07FUMP REPLACEMENT /_7 <br /> Other / / E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I PIT PRIVY <br /> ..SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> }'PROPERTY LINE - PRIVATE DOMESTIC &L PUBLIC DOMESTIC WELL �) <br /> INTENDED USE TYPE OF WELL I CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable Tool Dia J of Well Excavation <br /> Domestic/private Drilled Dia. 'fof Well Casing <br /> f Domestic/public Driven ' Gauge of Casing `C <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 By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: jF State Work Done ( .,�,e-„M '.= � <br /> a <br /> pESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Y hereby agree to comply with all laws and regulations of the San Joaquin Local`Health District <br /> I 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 knowled rid-belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UNG AND A FINAL INSPE I N. ; , <br /> SIGNED ' TLE <br /> MAW T P N REV SE SIDE) <br /> I R DEPARTMENT: USE ONLY <br /> PHASE I +: <br /> APPLICATION ACCEPTEDBY DATE <br /> ADDITIONAL COMMENTS: ' <br /> } PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY DATE ffi!{,-H , <br /> J <br /> E H 1426 _ Rev. 1-74 1-74 2M <br />