Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <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 /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 i <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 Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION () - �I�N/�/lTics/� f'�nd CENSUS TRACT <br /> Owner's NamefPhone& ZzI 2g 3 <br /> Address qft !j' 6 )"zvz 0(f Ze A n/ City &Az <br /> L;i.&en�s"e.#Contractor's Name ufmot lgcq / i _.P�hone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / 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 O. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 1--Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth, of Grout Seal fi <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal' Installed By: <br /> PUMP INSTALLATION: Contractor 11pavewfal / l <br /> Type of Pump H.P. T I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: - /7/ State Work Done"Add T n4. <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 <br /> (PRAW PLOT PLAN ON REVERSE SID i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: , <br /> PHASE IIOOTZ INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY - DATE INSPECTION BY DATE �i-2• <br /> F M 1G?( fie.. 1-7 A <br /> 1177 2M <br />