Laserfiche WebLink
SAN JOAQUIN'.LOCAL�-HEALTH DISTRICT <br /> FOArOFFICE USE: 1601 E. Hazeltori'Ave.; Stockton, Calif. <br /> Telephone_: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. e77-aVP <br /> THIS PERMIT EXPIRES I,YEAR FROM DATE -ISSUED 5e 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. 11862 and tine .Rules and" Regulations of the San. Joaquin Local Health District. <br /> JOB ADDRESS/LOCAT N �_ CENSUS TRACT <br /> Owner's Name - Phone Z42 _ <br /> Addr`ess. .. /..rte- �.�.. .. _. City c , <br /> Contractor's Name License Phone <br /> uk Yk .► ter, ,. :\': i:, . . <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN j-7 RECONDITION /? DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> Pump REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: ASEPTIC TANK.._ SEWER LINES ,: PIT. PRIVY <br /> SEWAGE DISPOSAL fib, _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE •DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 4 ^ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation'' <br /> Domestic/private Drilled Dia.*#of=`W611,Casing <br /> Domestic/public, Driven Gaugd-bi"Casing <br /> 'Irrigation � ' Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary .Ty* of Grout <br /> Disposal Other Other Information _ w ' <br /> Geophysical �--- - "'3urface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 3 . <br /> Type of Pump ; H.P. <br /> PUMP REPLACEMENT: / / State Worts Done <br /> PUMP `Zz= .REPAIR: State Work Done <br /> RES-T RUCTION OF WELL: Well Diameter } Approximate Depth <br /> Describe Material and Procedure <br /> J i <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 my work on a new well, I will fuxnish the San Joaquin Local Health District a <br /> WELL DRILLERS of the well and notify them before putting.the. well in use. The above <br /> information is u . �" heb at o my.knowledge'"and belief. I WILL CALL FOR A GROi1T INSPECTION <br /> PRIOR TO GROU IN PE CFION. „ . <br /> SIGNED TITLE <br /> I <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FORDEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BY —� DATE '7 /J <br /> 02 ADDITIONAL COMMENTS: <br /> # PHASE II1iGR0UT INSPECTION ; P F AL INSPECTIO <br /> INSPECTION BY gip' DATE INSPECTION BY A, DATE <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br /> Ip 5` 2*. <br />