Laserfiche WebLink
' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F06� OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7'-Sa9/C' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> pplication 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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .OB ADDRESS/LOCATION i t�s � - Z2 CENSUS TRACT <br /> weer'e Name Phone 7 <br /> Address /( City j <br /> contractor's Name ��- . �os� License #2 v Phonee <br /> Sys- z s <br /> YPE OF WORK (Check) : NEW WELL DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /37 PUMP REPLACEMENT /7 <br /> Other / / - <br /> -[STANCE TO NEAREST: SEPTIC TANK tvp ' 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 X' Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing g'^ <br /> Domestic/public Driven Gauge of Casing 1-2— <br /> Irrigation Gravel Pack Depth of Grout Seal 6-4 , <br /> Cathodic Protection Rotary Type of Grout [� k <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> JMP INSTALLATION: Contractora�-- _ C <br /> Type of Pump H.P. 3 <br /> "'!MP REPLACEMENT: / / State Work Done \ <br /> PQMP '.REPAIR: State Work Done <br /> STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> d 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 /> "LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> i formation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> TIOR TO GROUTING AND A FINAL INSPECTION. <br /> iIGNED TITLE <br /> �. <br /> JDRAW PL LAN ON REVERSE SIDE) <br /> FOR EPARTMENT USE ONLY <br /> 'RASE I <br /> PLICATION ACCEPTED BY DATE �17/-7 <br /> 4�DITIONAL COMMENTS: <br /> PHASE II GR IJ S , CTIO PHASE III/FINAL INSPECTION <br /> SPECTION BY DATE INSPECTION BY DATE <br /> F •i lL9A n.,.. i_�i ._� <br />