Laserfiche WebLink
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. ��� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby 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 and Regulations of the San Joaquin Local Health District. <br /> CS::iii •.i�� : <br /> JOB ADDRESS/LOCATION IL 62& `R-06010 Q CENSUS TRACT O�`l- 0(00'6y0 <br /> Owner's Name �a LA Y L ON Phone I <br /> Address <br /> &W14l� City *'74 <br /> UAWContractor's Name C Q� W'��.L � � License # [�02, Phone (, S� y <br /> i �R <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION /7 ` <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 1. �Q 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 IO" <br /> Domestic/private Drilled Dia. of Well Casing '+ <br /> '�` ' � <br /> Domestic%public Driven � Gauge,of'�Casing <br /> Irrigation avel Pack � � Depth of' Grout Seal ' <br /> Cathodic Protection Mary y . _- Type of Grout de Of g&T cleo <br /> Disposal . Other Other Information <br /> Geophysical � Surface Seal Installed By: <br /> \ 4 <br /> PUMP INSTALLATION: Contractor <br /> ' } Type of Pump H.F. <br /> PUMP REPLACEMENT / / State Work Done`, <br /> PUMP .REPAIR: / / State Work Done!'. '' . 4 <br />�DESJRUCTION 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 Distract <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 PORT of the well and notify #them before putting the. well in use.. The above <br /> Einformation jrue o the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G N D A FINAL INSPECTION. ,. r <br /> SIGNED TITLEID� � <br /> (DRAW PLOT PLAN ON REVERSE SE) <br /> . FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P E O�DA!TE <br /> IO P / NAL INSPEC 0 <br /> INSPECTION BY 2[Y INSPECTION BY <br />