Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. _ : <br /> Ly Telephone : (209) 466-6781 C <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue <br /> In <br /> ,pplication is hereby made to the San (Joaquin eLocal rHealth tDistrict for a permit to <br /> n <br /> and/or install the work herein described. This application is made in compliance withSanuJo�quin <br /> ;ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 0$ ADDRESS/ SON <br /> CENSUS TRACT <br /> wner's Name <br /> Phone <br /> ddress ' <br /> City S��� <br /> ontractor's Name 444Q1) rKl <br /> License �f7hone <br /> YPE OF WORK (Check) : NEW WELL ZRF DEEPEN /_% RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION YX PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> ISTANCE TO NEAREST: SEPTIC TANK�'�j�) SEWER LINES�c���PIT PRIVY .* <br /> SEWAGE DISPOSAL FIELD /�Q -CESSPOOL/SEEPAGE PITL��r��—pTHER <br /> PROP�;RTY LTN���I�IATE DOMESTIC WEL ��PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> IndustrialCONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing 7 <br /> Domestic/public Driven - <br /> Irrigation <br /> riven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other <br /> Other Information <br /> Geophysical Surface Seal Installed By: <br /> 7MP INSTALLATION: Contractor �-c1 <br /> Type of Pump S, <br /> H.P. <br /> JMP REPLACEMENT: / / State Work Done <br /> JMP .REPAIR: State Work Done <br /> '.S•TRUCTION OF WELL: Well Diameter ! <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> id the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> iter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> Zformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> J OR TO GROUTING AND A FINAL INSPECTI <br /> CGNED <br /> W PL L ON REVERSE SIDE) <br /> SASE I FOR BEP TMENT USE ONLY <br /> ?PLICATION ACCEPTED BY DATE ,�/ 7 <br /> )DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS Tj2/F NAL INSPECTION ' <br /> ASPECTION BY �� t„ BATE 0. i - <br /> j t INSPtCTION BY r - DATE <br /> ' r <br /> . 1 /77 9M <br />