Laserfiche WebLink
SAN JOAQUIN LOCAL:HEALTH DISTRICT <br /> I'OPf=O�FCE USE; ' 1601 E. Hazelton Ave. , .Stockton, Calif. t <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> 1/ �no�!� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is iereby 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 ad Regulations of the San Joaquin Local Health District.. <br /> PY-CENSUS TRACT _ <br /> JOB ADDRESS/LOCATION <br /> 0. <br /> Y Phone. <br /> Owner's Name <br /> City <br /> Address <br /> License # Phone <br /> I Co%itractor's Name <br /> iE OF WORK (Check) : NEW WELL DEEPIN / / -7 <br /> PUMP­ <br /> DESTRUCTION /_7 <br /> i PUMP•INSTALLATION +/z / + PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT-PRIVY 1 <br /> KI <br /> . r <br /> SEWAGE ,DISPOSAL FIELD -f-CESSPOOL/SEEPAGE PIT OTHER LV-ELL-.25 <br /> } PROPERTY LINE. -- PRIVATE _DOMESTIC WELL -- PUBLIC DOMESTIC WELL <br /> E INTENDED USE TYPE OF WELL •CONSTRUCTION SPECIFICATIONS <br /> i+ <br /> Industrial O� �. _r Cable Tool Dia. of.Glell Excavation +f <br /> Domestic/private <br /> Drilled -, .:art Dia. of Weft Casing <br /> Domestic/public =., EDriven Gauge of Casing <br /> .. Irrigation I., - Gravel Pack 'Depth of Grout Seal <br /> Cathodic Protection Rotary.. Type of Grout <br /> t,., Disposal ' Y _ <br /> Other Other Information <br /> Geophysical p Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type- of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> T` <br /> PUMP REPAIR: State Work Done <br /> . �I <br /> Y <br /> D UCTION. OF :' We— ,�Di,ameter- a--.. . .".Approximate Depth <br /> ® Describe Material. and Procedure 111100 <br /> GCMG <br /> with 1 laws and egulations�o£ the San Joaquin Local Healt �Strict <br /> I herheb_y,agzee„oto comply.._ --- ---..�'"'a"..'�j j r j'o ,-� <br /> and the State of California pertarnTn <br /> to or regulating well ''eonstructiion. Within FIFTEEN DAY <br /> after completion of my work on anew well, I wi11 furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT ofthe well and notify them before putting the .well in use. The above <br /> F information is true to thelbest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A -Fi41CFtySPECTION TITLE -_ <br /> SIGNED - - <br /> i (DRAW OT PLAN ON-RE SE SIDE)_ <br /> DEPARTMENT E ONLY I AI _7 <br /> E 6 X <br /> PHAS M � `�” DATE 571 <br /> APPLICATION AC EPTED BY. , <br /> ADDITIONAL COMMEN PHASE III/FINAL NSPECTION <br /> p g I Oil INSPECTI <br /> IIN INSPECTION BY / DATE _ T- <br /> k, INSPECTION BY DATE 77 <br />