Laserfiche WebLink
�* <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> [FOF- OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (204) 466-6781 <br /> ` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,7,7: , <br /> z THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/D <br /> (Complete In Triplicate) ' <br /> Application is hereby made to theFSan Joaquin Local Health District for a permit to construct <br /> and/or in the work herein described. This application is made incompliance with 'San Joaquin <br />-,rCounty. 0tdinance No. 1862 and the Rules and Regula.tions' of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION f� © CENSUS TRACT <br /> Owner's Name; Phone l <br /> Address City <br /> Contractor's Name` / h Z4- License # cf{l�hone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> :DISTANCE TO NEAREST: SEPTIC TANK SEWER„.LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE 'PRIVATE DOMESTIC WELL X_� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool - Dia, of Well Excavation ” <br /> Domestc/private --,._ Drilled-�.,..; _Da. .of. We11Casing ____ -- <br /> Domestic/public Driven Gauge of Casing � <br /> Irrigation V Gravel Pack Depth of Grout Seal r <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ,. <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor '+ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> Jj <br /> PUMP .REPAIR: / ./ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL 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 GROUTING AND A FIVAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW. PLOT PLAN ON REVERSE SIDE)_-__. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY /.<- DATE v ,I.NSPECTION BY /°� DATE <br /> E H 142 b <br /> 6/7VIC <br /> -2M . <br />