Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ,FOR OFFICE USE: 1601 E. Hazelton AV9. , 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 /may'7 <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 /> iertsmy Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ADDRESS/LOCATION �� S S CENSUS TRACT <br /> Name , Q Phone <br /> p <br /> Ad�resss O � �� Cit <br />`Contractor's 'Name //0 �,. License # &e, )''Phone rld/Z;s;�S'~ <br /> TYPE OF WORK (Check) : NEW WELL J�r/ DEEPEN /_7 RECONDITION /_/ DESTRUCTION /_ _ 1 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / / vl <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK,/4 SEWER LINES ! d PIT PRIVY �a— <br /> SEWAGE DISPOSAL FIELD --&- CESSPOOL/SEEPAGE PIT--,a- OTHER -99' �[ <br /> PROPERTY L INdA PRIVATE DOMESTIC WELL ` 0 PUBLIC DOMESTIC WELL -.ep- _ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> d_ Domestic/private _ Drilled Dia, of Well Casing ��-- <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation A Gravel Pack Depth of Grout Seal <br /> Cathodic Protection -e Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed B -X�/- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ��_ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / J State Work Done <br /> ES TRUCTION OF W We 11ganfe <br /> 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 INSWCTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I.TINAL,INSPECTION <br /> INSPECTION BY DATE Z INSPECTION BY Z DATE <br /> {) / / '�,d'? y�,Q r� �ar CSS•. <br /> .. F. H'-1426_ a�Rev_._.�2_-N /7 / 7 Y 61 .;, 61/77 2m <br /> - - - <br />