Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <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. 76-S3P <br /> THIS PERMIT EXPIRES l YEAR FROM DAT_E 'ISSUED Date Issued 72- <br /> (Complete <br /> 7(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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _o2-")Z97 &9rcl CENSUS TRACT <br /> Owner's Name i/ �' Phone 'Rea <br /> Address h'12Gi City Irl <br /> Contractor's Name License #p� Phone ' bPOZ <br /> TYPE OF WORK (Check) : NEW -WELD /7 DEEPEN 17 RECONDITION /7 DESTRUCTION f7 <br /> .PUMP INSTALLATION/ / PUMP REPAIR-J PUMP REPLACEMENT /7 <br /> Other <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. 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 i <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> -Type .of -Pump-- _ . -. �, ��. .._- . ,� w . 'HO'P. <br /> PUMP REPLACEMENT: / / Statae Work Done <br /> PUMP :REPAIR: State Work Done t <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 f <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 GROUT INSPECTION <br /> PRIOR TO GROUTW AND A NAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �~7 <br /> AP.PLICATION" ACCEPTED BY, DATE ' / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II INSPECTIO <br /> INSPECTION 'BY DATE INSPECTION BY DATE <br />