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. g <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued !� <br /> (Complete In Triplicate) a <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 /> � 4 <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name C' r° Phone <br /> Address v c City "_ ye2f, <br /> Contractor's Name License �}/dPhone <br /> TYPE OF WORK (Check) : NEW WELL J / DEEPEN f / RECONDITION [—/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> w7 Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY : <br /> SEWAGE- DISPOSAL FIELD -CESSPOOL/SEEPAGE PIT m OTHER <br /> x. ti <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL A CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing .J <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack"' Depth of Grout Seal <br /> Cathodic Protection Rotary - Type of Grout <br /> Disposal Other _ Other Information j <br />—Geophysical Surface <br /> Seal Installed By: -- <br /> PUMP <br /> y: -PUMP <br /> C <br /> INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ( State Work Done <br /> _ I <br /> PUMP -.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> T 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 G TING AND A FINAL INSPECTION. <br /> SIGNED ` 407 TITLE &"AALQ fA <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _% Ze 77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II CIROUT INSPECTION PHA jr/F <br /> aNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYjZUj DATE 3?113 77 <br /> P u 1L9A De 1_71, 1177 . ., 2M <br />