Laserfiche WebLink
i <br /> CJa.y,.. p. �. SAN JOAQUIN LOCAL HEALTH DISTRICT € <br /> POF :OFFIC 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 Z <br /> ;( (Complete In Triplicate) <br /> Application is hereby made totthe San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This appXication is made in compliance with San Joaquin <br />. County Ordinance No. 1862 and1the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ CENSUS TRACT <br /> Ovner's Name Phone <br /> Address <br /> Citysq4o � k <br /> Contractor's Name ct W_ ? License # -3�yd Phone V1.y <br /> TYPE'OF WORK (Check): NEW WELL '/7 DEEPEN '/_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR &-7—PUMP REPLACEMENT 17 <br /> Other / / <br /> .A I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> yySEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 4- CONSTRUCTION SPECIFICATIONS � a <br /> f _ Industrial t Cable Tool Dia. ofvWell Excavation V 3 <br /> hr Domestic/private Drilled Dia. of>Well Casing <br /> 7'""` Domestic/public i Driven Gauge of Casing f� <br /> Irrigation- .1 Gravel•,Pack Depth of Grout Seal L <br /> Cathodic ProtectionT 'i- Rotary Type of Grout ' <br /> Disposal t Other Other Information <br /> Geophysical Surface Seal Installed 'B i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H-'P.'.��^ <br /> PUMP REPLACEMENT: . / / State Work Done <br /> .PUMP REPAIR: /�/T State Work Done �-f.�� f � <br /> ,. 3 <br /> PE&TRUCTION 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=be ief. I WILL' CALL FOR A GROUT INSPECTION. <br /> PRIOR TOG TING AND A FINAL INSPECTIO <br /> . SIGNED a TLEi�.l� <br /> DRAW W I,'AN ON REV SE SIDE <br /> . VDA DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> F'H 1426 Rpv_ 1-74� " <br />