Laserfiche WebLink
i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFx7OFFICE USE: 160 E. Razelton Ave. , Stockton, Calif. <br /> 1 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 26_,;�ijyo <br /> THIS PERMIT EXPIRES ] YEAR FROM DATE ISSUED Date Issued -iS:76 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local €;ealth District for a permit to construct <br /> and/or install the work herein described. <br /> This <br /> application <br /> the Sanmade <br /> Joaquincompliance <br /> Health San <br /> DistrictJoaquin' <br /> County ordinance No. 3862 ands the Rules and Regulations <br /> JOB ADDRESS/LOCATION GU 4CENSUS TRACT <br /> Owner's Name _ _ Ph one Z <br /> Address 0 .c-o �c- City <br /> Contractor's Name. CJ _ License VLL3?3 Phone 6 0 M(. <br /> TYPE OF WORK (Check): NEW WELL, L7 7 DEEPEN '-/ - RECONDITION IDESTRUCTION I? <br />` PUMP ;INSTALLATION PUMP REPAIR /� PUMP REPLACEMENT 0 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL: PUBLIC DOMESTIC WELL v <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation \ <br /> Domestic/private i Drilled Dia.,of Well. Casing Y _ a <br /> Domestic/public I DrivenGauge of Casing <br /> Irrigation i Gravel Pack W Depth of Grout-`Seal.•"`"` <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal F Other Other Information ' <br /> Geophysical -Surface Seal Installdd 'By. <br /> PUMP-INSTALLATION: Contractor /O <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / /. .State Work Done <br /> PUMP '.REPAIR: / State `Work Done <br /> a x <br /> r DESTRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> Describe Material and Procedure <br /> I hereby agree to comply with all flaws 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 /> i after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> f WELL DRILLERS REPORT of thel well and notify them before putting. the..well. in.use.... .The above <br /> information is ue to-the-bestof myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU AW A_FI�PECTION. - <br /> SIGNED TITLE <br /> ,. (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , - <br /> APPLICATION-ACCEPTED BY j DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRAS INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -� <br />