Laserfiche WebLink
JOAQUIN LOCAL HEALTE DISTRIC' <br /> �OR CFFICE USE: .1601. . Hazeltcn Ave, , Stockton, Cal a'. <br /> I r. Telephone: (209) 466-6781 <br /> bt`=" APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1�2-30 76 <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 'Joaquir <br /> 7unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION5 �: -T - 7C ; ' CENSUS TRACT <br /> 1 ,�ner T s Name �} -� Phone el <br /> �4.dress /(,5` l�� (Lc•�/ City <br /> Contractor's Namet li A License # ? i� Phone -52 2 W43 <br /> r ? <br /> 'iiPE OF WORK (Check) : NEW WELL /LJ' DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / J PUMP REPAIR / / PUMP REPLACEMENT _7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK fi �n� SEWER LINES PIT PRIVY <br /> `r SEWAGE DISPOSAL FIELD ��� CESSPOOL/SEEPAGE PIT OTHER <br /> 1 PROPERTY LINE = PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> t- Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well CasingN ,n(/�� �a <br /> omestic/public , Driven Gauge of Casing <br /> Irrigation Gravel Pack Dc-i h of- iraut.:Seal - <br /> -:;ate-�_>.�=- �' - <br /> Cathodic Protectf r Rotary Type of Grout C, <br /> Disposal Other Other Information _ G <br /> Geophysical Surface Seal Installed By: '� . e <br /> .JMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> F2tREPLACEMEXT: - State Work Done' <br /> REPAIR: / / State Work Done <br /> ,zS•TRUCTION 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 /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> FEter completion of my work on a new well, I will furnish the San Joaquin Local Health Dis't•r1a, a <br /> ELL 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 GR UTING ANDA NAL IN I'ECTTON. , <br /> IGNEDTITLE / <br /> •i <br /> (DRAW DOT ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY. ✓.,,�_ <br /> RASE I ,! • <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHA JI 43iOtIT INSPECTIQN PHASE IIIJZINL INSPECTION <br /> FNSPE TION BY `DATE ;"' INSPECTION BY DATE <br />