Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE 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) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct t <br /> and/or install the work herein described. This application is made in compliance with San Joaquinj <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CSS 1�+ +�+� ' CENSUS TRACT �- <br /> Owner's Name kV2 Phone <br /> Address ��� o <br /> �i city 'e g t= '.✓ <br /> Contractor s Name <br /> �--0 � License 4� I' .Phone - <br /> r <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN / / RECONDITION / / DESTRUCTION TF <br /> PUMP INSTALLATION/ / PUMP REPAIR 1 PUMP REPLACEMENT /7 <br /> Other ] NVE) L AY uk-4a I.C, <br /> AZ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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. .pf,Welh Casing._. (v <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 Y <br /> Geophysical Surface Seal Installed B : <br />} PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done > <br /> DESTRUCTION OF WELL: Well Diameters 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 s <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 GRO I G AN A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW.:PT POT' FLAN ON RE ERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE rzl <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN PECTION PHASE'Ir I/F NAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ra 3/76 2M <br />