Laserfiche WebLink
~ SAN JOAQUIN LOCAL ,HEALTH. DISTRICT . <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. l <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT - mi 77-1/�� <br /> THISPERMIT 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: 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � .,, __.._. CENSUS TRACT <br /> Owner's Name C�� � —�ocn/ .. .,. _..,. ., .._.,. ._— Phone <br /> Address City <br /> JV <br /> Contractor's Name License ._ -Phone �r <br /> 4 j i <br /> TYPE OF WORK,,. (Check) : NEW WELL .DEEP�k /_ /. RECONDITION / / -DES_TRUCTION /-7 , <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY = <br /> SEWAGE DISPOSAL- FIELD CESSPOOL/SEEPAGE PIT�-7 —OTHER <br /> PROPERTY LINE --'PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial f Cable Tool Dia. of Well Excavation 71-9 <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public f Driven `t Gauge of Casing >. { <br /> Irrigation Gravel -Pack- .-Depth- of Grout Seal p <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal E Other Other Information <br /> Geophysical Surface Seal Installed B , <br /> PUMP INSTALLATION: Contractor <br /> Type of. Pump 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 GROU;;IN2 AND A. FINAI,INSPECTION, <br /> SIGNED TITLE e_:Z�z <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY /J <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' !� <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECT N 'PRASE III/FINAL -INSPECTION <br /> INSPECTION BY DATE INSPF,GTION"BY'- DATE <br /> -i: <br /> 1l"f 7 <br /> F, H 142F, Rau- 1-71-74n i7 <br />