Laserfiche WebLink
' V SAN JOAQUTN LOCAL HEALTH DISTRICT �� <br /> F ;ZFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a- L'4�1 <br />! THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7� <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 /> f JOB ADDRESS/LOCATION i 3 7 � !� CENSUSTRACT . <br /> Owner's Name , , l r CpO Phone �3Z: 15 Z,S <br /> Address City , 3X e k <br /> 1 <br /> Contractor's Name SI License # ` Phone -- : <br /> TYPE OF WORK (Check) : NEW WELL '/_7 DEEPEN '/7 RECONDITION /-7 DESTRUCTION /7 <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 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial j Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation tGravel Pack Depth of Grout Seal . <br /> Cathodic Protection Rotary Type of Grout' <br /> Disposal i Other Other Information <br /> Geophysical Surface Seal Installed 'B <br /> k' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump, [ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to complyiwith all..Iaws. 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 UTING AND A FINAL INSPECTION. <br /> SIGNED A TITLE <br /> F (DRAW PLOT PLAN ON REVERSE SIDE <br />! <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY. <br /> APPLICATION ACCEPTED BY DATE <br />:r ADDITIONAL COMMENTS ZL <br /> PHASE II GROUT IN LECTION PHASE TIZ/FIIJAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE �I <br /> E H 1426 o RAvr_ 1_7A r f �.J <br />