Laserfiche WebLink
- . -� * . <br /> 66 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOTO,OFFICE USE: ,' j 1601 E. Hazelton Ave. , Stockton, Calif. <br /> l/ Telephone: (209) 466-61$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No..7�l�-sem� i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br />.Application is hereby made tolthe San Joaquin Local health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin' <br />.County Ordinance No. 1862 andithe Rules and Regulations of the San Joaquin Local -Health District. ` <br /> JOB ADDRESS/LOCATION R F7=T-G pian/ CENSUS TRACT o5'r d 70z 7 <br /> Owner►s Wai � Z v Phone • <br /> Address 1 1 o fL: City . . Lord <br /> C6ntractor's Name License # 2-*$C1r.rPhone <br /> . <br /> TYPE OF WORK' (Check): NEW WELL /..:_ DEEPEN '/7 RECONDITION /-7DESTRUCTION <br /> PUMP INSTALLATION /�7PUMP REPAIR/ J PUMP REPLACEMENT <br /> Other / / <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK 70 . 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 s <br /> Industrial Cable Tool Dia, of Well Excavation 7�— <br /> _r/Domestic/private ! Drilled Dia. of Well Casing <br /> Domestic/public f Driven Gauge of Casing y- <br /> Irrigation I Gravel Pack Depth of Grout Seal SQ <br /> Cathodic Protection r3 Rotary Type of Grout ' 7 fm _ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump <br /> PUMP REPLACEMENT: ... / / State Work Done <br /> i 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 /> 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 therm before putting the..wel,1. in.use.. . .The above <br /> ( information is true to thee <br /> • st of my owledge and belief. I WILL CALL 'FOR A 'GROUT INSPECTION <br /> . PRIOR TO GROUTING AN F SP I . <br /> SIGNED TITLE <br /> -_ (DRAW PLOT PLAN ON REVERSE SIDE <br /> r FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPl3CTI N ��� <br /> INSPECTION BY , .� DATE --i 0��� INSPECTION BY C . 6 DATE'/o' <br />