Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> FOB OFF CE USE: . 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77' <br /> « THIS PERMIT EXPIRES 1 YEAR FROM DATE" ISSUED Date Issued 1 <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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. y <br /> JOB ADDRESSAOCATION („� ' .`7` �a� CENSUS TRACT <br /> Owner's Name ya Phone <br /> Address` , _� City - <br /> Contractor's Name License # 1 y hone 44Cv �,� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /_/ DESTRUCTION /_ f <br /> PUMP INSTALLATION / / PUMP REPAIR REPLACEMENT /_7Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT. PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 1 <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 /> �C_ Domestic/private Drilled . Dia. of Well Casing <br /> `Domestic/public Driven Gauge of Casing <br /> Irrigation r. Gravel Pack . Depth of Grout Seal \, <br /> Cathodic Protection Rotary Type of Grout V <br /> Disposal Other - Other Information <br /> Geophysical <br /> Surface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump s Z H.P. lr- <br /> FUM' REPLACEMENT: State Work Done e/ �✓ ,fj ` N4j 4,-,ja,li . <br /> PUMP ".REPAIR: /./ State Work Done <br /> DESTRUCTION OF WELL: 'Well Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> 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 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 thewell in use.. . The above <br /> information is true to the be f. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOg5LUTING AND A FINAL P UN. <br /> SIGNED( ITLE <br /> } f (T)RALUPLOT PLAN ON R ERS SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE < ,` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INS&fCTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />