Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH-DISTRICT . <br /> i?Oh OFFICE SE: 1601 E. Uazelton Ave., Stockton, Calif. _ <br /> Telephone: . (209)'466-6-781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�� <br /> THIS PFRMIT:EXPIRES 1 YEAR FROM.DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> '•Application is h'eieby 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 CENSUS TRACT <br /> Mules and Regulations of the Joaquin Local Health District. <br /> / T Pj / .0 A � d� s . tee+ <br /> JOB ADDRESS/LOA <br /> Phone <br /> Owner's Name 7 City 94/G--r f� L <br /> Address. <br /> p r C Ir c�D <br /> Contractor's Name . License <br /> TYPE OF WORK (Check): NEW WELL /-T DEEPEN / 1. RECONDITION /-T DESTRUCTION /_T <br /> PUMP INSTALLATION / / PU?V REPAIR-/+;PV~rrM REPLACEMENT /T <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER _ • - S <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC D(lKESTIC WELL QC <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 'j Domestic/private <br /> Drilled Dia. of Well Casing T <br /> Domestic/public Driven Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Irrigation <br /> -Cathodic Protection i Rotary Type of Grout <br /> ' <br /> Disposal Other Other Information <br /> Geophysical _ Surface Seal Installed B � <br /> a <br /> PUMP INSTALLATION: ContractorH.P. - - <br /> ' Type of Pump <br /> PUMP. REPLACEMM - 4- �/ / t State Work Done a4* y <br /> PUMP :REPAIR: State Work Donest LAO-6 <br /> DESTRUCTION OF'WELL: Well Diameter Approximate Depth _ <br /> Describe Material and Procedure i * <br /> I hereby agree `'to comply with all laws and regulations of the San Joaquin Local Health District. <br /> • and the State of California wlYpertaining 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' <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 know a and�b Ai_e . I WILL CALL FOR A GROUT INSPECTION <br /> !PRIOR TO GROUTIN9 AND A F16AL INSPECT _ <br /> i SIGNED - ­_ '`� � . <br /> DRAW OT PLAN ON REVERS SIDE) *' <br /> 1 ARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMHENTS: PHASE III FINAL INS ECTIO,N <br /> PHASE II GROUT INSPECTION INg2ECTION BY DATE <br /> ; INSPECTION BY DATE <br /> 4 u ILIA vo,T_ 1-74 <br />