Laserfiche WebLink
SAN JOAQUIN �OCAL- HEALTH DISTRICT t <br /> FOR OFFICE USE, 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: - (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ' <br /> Date issued S � ,� <br /> fF THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED - <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct a � <br /> in <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 ADDRSSS/LOCATION � �� �d11. TQC,k Tei -y ��'�� �"'� CENSUS TRACT <br /> Phone <br /> Owner's Name a r <br /> City <br /> Addresseo <br /> Contractor's Name , o 2 <br /> License ��� ` 71ahone . <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / N; <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES _ PIT PRIVY�..__ O <br /> SEWAGE DISPOSAL FIELD CESSPOOL/S'EEPAGE-P IT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL-� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE -OF..WELL. _� _ -,, Y. ._.CONS-TRUCTION-SPECI.FICATiONS <br /> .y ... <br /> Industrial Cable Tool Dia. of Well Excavation <br /> F! <br /> Domestic/private ��!-- Drilled Dia. of We11 Casing vG, <br /> Domestic/public Driven Gauge of Casing o <br /> Irrigation Gravel Pack Depth of Grout Seal S-4 F <br /> Cathodic Protection _ Rotary Type of Grout e el <br /> Disposal Other Other Infarmatian <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.: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth wl. <br /> Ef 3 <br /> j Describe Material and Procedure <br /> 4 <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 Districts <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 INSPECTION <br /> ! PRIOR TO,.GROU-TING,.AND.--.ATI-NAL JNSPECTION:c -�- ` "" " �' '" '� .'�.•. f <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY � <br /> f � <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY I. <br /> ADDITIONAL COMMENTS: ., <br /> PHAS <br /> PHASE II GROU INSPECTION E II /FINAL INSPECTION fI <br /> E INSPECTION BY DATE INSPECTION BY DATE i <br /> a-141 �6Zfo/77 _ 2MJ1: <br /> i <br /> V U 1Lg9 .,bo„ . 1_7L <br />