Laserfiche WebLink
SAN JOAQUIN LOCAL. HEALTH DISTRICT w4FOR.','OFFICE USE 1601 E. Hazelton Ave. , ,Stockton,, Calif. <br />T ` <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.YVI <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br />I <br />Application is hereby made <br />Complete In Triplicate) <br />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. vrith .San JoaquinCountyOrdinanceNo. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />JOB ADDRESS/LOCATION <br />2,3 -1MfCIA" ffX C NSUS TRACT <br />Owners Nacre <br />one UOZ 3- 157-3/3- <br />Ad dressAddress 2 5. City Q <br />a <br />Contractor's Name Y,( /7n f',. <br />TYPE OF WORK (Check) : NEW WELL/ DEEPEN '/—/ RECONDITION /-7 DESTRUCTION /7 <br />PUMP INSTALLATION./ / PUMP REPAIR /-7 PUMP REPLACEMENT /? <br />Other 1/ / q <br />DISTANCE TO NEAREST: SEPTIC ,TANK SEWER LINES PIT PRIVY <br />SEWAGE DISPOSAL FIELD /FDS <br />CESSPOOL/SEEPAGE PIT OTHERfeU- 91> <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 />Domestic/private Drilled Dia. of Well Casing <br />Domestic/public Driven Gauge of Casing <br />Irrigation Gravel Pack Depth of Grout Seal <br />Cathodic Protection - Rotary Type of GroutAm <br />Disposal Other Other Information' <br />Geophysical Surface Seal Installed B : <br />ti <br />PUMP INSTALLATION: Contractor <br />Type of Pump H.P. <br />PUMP REPLACEMENT: State Work Done w ! <br />P State Work Done <br />a o 4 <br />DESTRUCTION OF W LL: Well Diameter f AppATmat6 ep[Ti''! <br />Describe Mater€ia1- and Procedure <br />I hereby agree to comply with all laws and regulations of the, Sari Joaquin Local Health District <br />and the..Staterof California-pertaining to-.or-regulating well'`,construc tion. Within FIFTEEN DAYS <br />after completion of my :%rock on,a,news,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 o£ my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIONPRIORTOGRUTZNGANDNALINSPTION. <br />SIGNED TITLE , <br />DRAW.P OT PLAN ON REVERSE SID <br />PHASE I <br />FOR DEPARTMENT USE ONLYI <br />APPLICATION ACCEPTED BY ! DATE 7 <br />ADDITIONAL COMMENTS:j <br />PHASE II GROUT INSPECTION PHASE IIJ/FINALII/FINALINSPECTION <br />INSPECTION BY DATE 5 -- --77 INSPECTION BY DATE 3 <br />F. 3/121 1D-- ' 1_7i ry 1/77 ?M