Laserfiche WebLink
SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> F'JE OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 23� <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 Joaquin <br /> County Ordinance No.. 6 ant-hie Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION e / V CENSUS TRACT <br /> � t 4 <br /> Owner's NamePhone Cf 7 V `L <br /> Address f C. Cites -- <br /> "; 16y;?, 7— <br /> c <br /> Contractor's Name _••, •,- . License ff Phone7�5 3 f 7 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL '/-W' DEEPEN / ./ RECONDITION /_/ DESTRUCTION /_7 ' <br /> PUMP INSTALLATION /F,? PUMP REPAIR / / PUMP REPLACEMENT /_7 <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 /> � H"omestic/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 9 <br /> Disposal Other ' Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor, r j <br /> Type, of Pump - -L4 ��, , `, H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: / -/ State Work Done <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED . ' TITLE i <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> _ FOR DEPARTMENT USE ONLY <br /> PHASE I - ""` y'1���� <br /> APPLICATION ACCEPTED BY DATE f"l <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOkV PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ./ - -7� <br /> �y <br /> 2M <br /> 1F7 <br /> R N '1 J-F, no,.- I_'7A - <br />