Laserfiche WebLink
a 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. 7 � <br /> THI91PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a-dal- 7 7 <br /> (Complete In Triplicate) v <br /> Application is hereby made to 'the San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereinldescribed. This application is made in compliance with San Joequin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION d CENSUS TRACT <br /> Owner's Name ' ' Phone <br /> Address / S` ��J21�1?�d•�/ - City <br /> I <br /> Contractorrs Name ; License <br /> _Phone <br /> f <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT X <br /> Other /L/ <br /> i <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 i Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation ! Gravel Pack Depth of Grout Seal <br /> Cathodic Protection .1 Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical t Surface Seal Installed By: I <br /> tI S <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 Diameter- --- x 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 /> lafter completion of my work on a new well, I will 'furnish the San Joaquin Local Health District a <br /> iWELL 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 G TjNjG AND A FINAL INSPECTJON. <br /> SIGNED TITLE <br /> f <br /> (DRAW PLOT PLAN ON REVERSE SIDE) l <br /> FOR DEPARTMENT USE ONLY g� <br /> 'PHASE I J , DATE 0 <br /> APPLICATION ACCEPTED BY (�J <br /> ADDITIONAL COMMENTS: r <br /> _PHASE II OUT INSPECTION F E FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> I <br /> 1Z7 2M <br /> 11 71 7 f.7G n..__ 1_7A - _ <br />