Laserfiche WebLink
i SAN JOAQUIN LOCAL HEALTH DISTRICT Y Y l <br /> 1 <br /> FOR:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S 333a lJ <br /> 7S 37fA . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 7.5� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local tfealth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with Safi Joaquin. <br /> ; County Ordinance No. 1862 and the Rules d Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOC ON CENSUS TRACT <br /> Owner's Name <br /> hotie ' <br /> Address z City ' <br /> LaContractor's Name 4 lZ� icense # . . Phone <br /> TYPE OF WORK (Check): NEW WELL '_ DEEPEN '�/ RECONDITION /� ESTRUCTION � <br /> ,i PUMP INSTALLATION J: ' PUMP REPAIR U P REPLACEMENT_ /-7 <br /> Other Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN 5 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD C S OOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVA E DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF NL2LL CONSTRUCTION SPECIFICATIONS <br /> ' <br /> Industrial able Tool Dia. of Well Excavation <br /> >90'mestic/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 Grout <br /> Disposal _. Other Other Information <br /> Geophysical Surf <br /> aoe Seal Installed 'B . <br /> PUMP INSTALLATION: ContractorL::::;z <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED. TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE ,z 2- 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY %/ ^ DATE - - .,-� INSPECTION BY DATE 7 - s;- <br /> R U '11.1)A n___ 4 s i 1. /•fes nye <br />