Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT 3 <br /> FOIw OFFICE USE: 1601 E. <br /> Hazelton Ave. , Stockton, Calif . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> a!'7 <br /> -� THIS PERMIT EXPIRES 1 YEAR FROM RATE ISSUED Date Issued _ ; <br /> ` (Complete In Triplicate) ' <br /> rmit to construct <br /> Application is hereby made to the San Joaquin Local Health District for a pe <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 /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> �� � ��� �Q � Phone (1{�i` <br /> Owner's Name _ <br /> City <br /> Address <br /> 1303 <br /> Contracto ' <br /> Co , License # �z(-Phone /(� Z Y, <br /> rs Name <br /> ii <br /> i <br />'-TY.PEi,OF,.WORK (Check): NEW-WELL--/ " DEEPEN I_/"'REC4NDZTION%7-D STRiJCTION I�T <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT (� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELB CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> TYPE OF WELI: �,,,,� CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE �-- <br /> Industrial 1 Cable Tool Dia. of Well. Excavation <br /> Dia. of Well Casing <br /> �. Domestic/Frivate t Dulled Gauge of Casing <br /> Domestic/public DrivenGravei Pack Depth of Grout Seal <br /> Irrigation rp Type of Grout <br /> Cathodic Protection_ 1 -4_Ro.tary yP <br /> Disposal ' � ..00her�. --S. Other Information <br /> i Geophysical -_ Surface Seal {Installed B : <br /> PUMP INSTALLATION: Contracto C {( H.P. 3 <br /> h Type of Pump <br /> PUMP REPLACEMENT.:——_ State Work Donees <br /> PUMP .REPAIR: State okDone <br /> _ - - - <br /> ',; ' ,:� Approximate Depth <br /> -,DES TRUCTION OF WELL: Well Diameter <br /> Describe Material and 'Procedure <br /> �. . <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> i.nd the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> ' <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> }sLL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> `irmation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 70 WING MD FINAL INSPECTION. TITLE <br /> I <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> E I DATE <br /> LICATION ACCEPTED BY <br /> DITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE �+-, - ' ° <br /> �:JSPECTION BY 1 DATE <br /> I 61177 _ 2M <br />