Laserfiche WebLink
SAN"JOAQUIN LOCAL HEALTH DISTRICT <br /> FO. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ! <br /> APPLICATFONIFOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z <br /> 77 yo 9 P ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 aC__;:7 <br /> (Complete In Triplicate) <br /> Application is hereby-made to the San Joaquin Local Health District for a permit to construct i <br /> and/or install the work herein deseribed. This application is made in compliance with San Jozquin .i. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> -I� <br /> JOB ADDRESS/�' ��5': h CENSUS TRACT <br /> Owner's Name ��� '_,n Phone <br /> Address _. -- I� City <br /> Contractor Name ' i / License �� hone, <br /> Cs \ r <br /> X. <br /> *=mow. � <br /> TYPE OF WORK (Check) : NEW WELL/ (DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other S <br /> .f <br /> DISTANCE TO NEAREST: SEPTIC TANK i 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 <br /> Geophysical Surface Seal Installed BY: <br /> Ij <br /> PUMP INSTALLATION: Contractor I. '�'� "" <br /> Type of Pump H.P. <br /> 'PUMP REPLACEMENT / / State Work Done <br /> PUMP--.REPAIR: / / State Work Done ^ <br /> ii <br /> fiDES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> y a Describe Material and Procedure <br /> I hereby agree to comply withl 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 /> iafter <br /> completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the we11 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 GROUTING AND A FINAL INSPECT <br /> SIGNED F E ,�- <br /> II DRAW P OT IAN ON REVERSE SIDE) 1 <br /> PHASE I FOR DEP ' TMENT USE <br /> ONLY <br /> f / <br /> II <br /> PPLICATION ACCEPTED BY DATE <br /> ,�: r <br /> ADDITIONAL COMMENTS: q <br /> PHASE II GROUT INSPECTION P S 141/FINAL INSPECTION <br /> INSPECTION BY' DATE !I INSPECTION BY DATE - b- <br /> , 1IZ7 2M <br /> Si 14 1V)F -hDoy. l_7A -. <br />