Laserfiche WebLink
SAV JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , 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 <br /> (Complete In Triplicate) r <br /> Application is hereby made, to the San Joaquin Local Health District for a permit to construct j <br /> and/or install the work herein described. This application is made in compliance with San Joaquin, <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. ' <br /> JOB ADDRESS/LOCATION lfllkt,l CENSUS TRACT - ` <br /> Owner's Name PhonAK- <br /> y x <br /> Address Gity�- a- -t3� <br /> i <br /> Contractor's Name License IVB 23?3 Phone3C, <br /> `i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES PIT PRIVY ,may`•. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 Casingi <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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor + `- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work none y` ` <br /> t <br /> PUMP . t < <br /> PCj` State Work Done <br /> .. <br /> DES TRUCTION'OF-WELL i" o_x_.imate 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 eo 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 puttingthe well in use. The above <br /> information is ue to the best of my nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI AND A FIJKL INSPECT N- <br /> SIGNED E 11 TITLE <br /> W PLOT PLAN ON REVERSE SIDE) <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . DATE 5 — <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL JNSPECTIOR <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> E H 1426 b/77 2M <br /> Rev. 1-74 ,- <br />