Laserfiche WebLink
FL„ ' �o� SP ,�JOAQUIN LOCAL HEALTH DISTRICT <br /> 'r'-0E OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> / THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - 71-1 <br /> t (Complete In Triplicate) <br /> f)lication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ind/or install the work herein described. This application is made in compliance with San Joaquin <br /> ►nty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> US ADDRESS ' QY' <br /> CENSUS TRACT <br /> R 7.e r's Name l'7SD Pf <br /> Phone <br /> Adrese �' ./ ! G City <br /> C;_,tractor's Name License �j/�j, �hone ' <br /> E OF WORK (Check) : NEW WELL / DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION � PUMP REPAIR ./7 ME <br /> PUMP REPLACENT /7 <br /> Other / / <br /> 1-TANCE TO NEAREST: SEPTIC TANK " - SEWER LINES PIT PRIVY <br /> SEWAGE DISPOPSL FIELD ��' CESSPOOL/SEEPAGE PIT/ I -/-.OTHER <br /> T PROPERTY LIN PRIVATE DOMESTIC WELL/.12- PUBLIC DOMESTIC WELL \� <br /> # INTENDED USE ?'YPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well ExcavationZ=11— <br /> Domestic/private v Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing 7_ <br /> Irrigation Gravel Pack Depth of Grout Seal �?-1 <br /> �-. Cathodic Protection Rotary Type of Grout ..� r <br /> _Disposal Other Other Information <br />�`- Geophysical Surface Seal Installed B <br /> F <br /> j,71 INSTALLATION: Contractor <br /> Type of Pump H.P. t��l <br /> J-r1 REPLACEMENT: /-7 State Work Done <br /> a <br /> JMP-- .REPAIR: <br /> / / State Work Done <br /> r <br /> 'RUCTION OF WELL: Well Diameter Approximate Depth <br />-� Describe Material and Procedure <br /> I ,reby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> h the State of California pertaining to or regulating well 'cons tru ct ion. Within FIFTEEN DAYS <br />:ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> IJ-, DRILLERS REPORT of the well and notify them before putting the..well in use.. The above <br /> i� rmation is true to the-best of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IOR TO GROUTING AND A FINAL INSPECT , <br /> ED <br /> PLO PLAN ON REVERSE SIDE , <br />[A,.S,E I FOR D PARTMENT USE ONLY <br /> 1 ICATION ACCEPTED BY DATE 7 <br /> jiA.TIONAL COMMENTS: <br /> PHASE If GROUT INSPECTION PHASE III FINAL INSPECTION <br /> S ECTION BY DATE INSPECTION BY ' DATE <br /> E H X26 uo„ ,-7L <br />