Laserfiche WebLink
SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FW OFFICE USE: 1601 E. Hazelton Ave. , Stockton, 'Cat f. ; <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;7 <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 pex-mit to construct <br /> and/or install the Mork herein described. This application is made In compliance with San Joaquin <br /> Count* Ordinance No, 1862 and the� Rules and Regulations of the`,San-. Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION &_4V_ CENSUSTRACT -ZOF aS_! -v7, <br /> Owner's Name „3VAIV <br /> 1zPhone <br /> Address � e <br /> City <br /> Contractor's Name =L,�� �n.� _ License <br /> Md Phone Wo�2c? ^ <br /> TYPE OF YORK (Check): NEW WELL /? DEEPEN /_7 RECONDITION /? DESTRUCTYON jY]" t � <br /> PUM ,INSTALLATION / 7 PUMP REPAIR / / PUMP REPLACEMENT UW <br /> � . <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 WELLCONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool r Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathddic, Rroiection Rotary Type of Grout <br /> Disposal 0-ther SO.ther_Informat4on._.. <br /> s <br /> Geophysical Installed BY: <br /> Surface Seal ins <br /> 'UMI' INSTALLATION:� Contrac,t-.r__-___ <br /> t Type of Pump ��{ H.P <br /> PUMP REPLACEMENT: <br /> / / State_Work--Done <br /> 'UNP REPAIR: 4211State Work Done <br /> E&TRUCTION OF WELL: Well Diameter <br /> Approximate Depth i <br /> Describe Material and Procedure, <br /> I hereby agree to comply with all laws and regulatious• 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,-1 wiil. furni.sh the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notifythem before <br /> putting the.-well in use. The above <br /> information is true to the-best-of- my knowledge and belief. ' I WILL GALL rOR A GROUT INSPECTION <br /> PRIOR TOM <br /> ING MR2 F AL INSPECTION. <br /> SIGNED s TITLE <br /> DRAW PLOT PLAN ON REVERSE SID6- <br /> P <br /> FOR DEPARTMENT USE ONLY <br /> HASE I <br /> APPLICATION ACCEPTED BY DATE r <br /> ADDITIONAL COMMENTS: E!7�_ <br /> PHASE II GROUT INSPECTION 'HAS 7I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ' _ DATE <br /> t _-E-H`1426 Rev. I-74 1-74 2M <br /> _. . <br />