Laserfiche WebLink
IL SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'OE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781ri �� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;% <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> )plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Vhd/or install the work herein described. This application is made in compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> aJB ADDRESS/LOCATION 3H,50 4 Lp hf_- -rev fZ- CENSUS TRACT <br /> per's Name T7_ Phone W7-o //p <br /> Address 5,0 City Damon 14 <br /> �3ntractor's Name `ftS_, . „`. �/ License U�27�()Zv Phone 0_7 <br /> tPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION gJ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> , ISTANCE 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 G <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing G <br /> Domestic/public Driven Gauge of Casing C <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information C, <br /> Geophysical Surface Seal Installed By: x <br /> JMP INSTALLATION: Contractor <br /> Type of Pump 3 H.P. a <br /> "UMP REPLACEMENT: 101 State Work Done <br /> FUMP .REPAIR: / / State Work Done <br /> iSTRUCTION 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 /> , nd 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 /> ""ELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above <br /> nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IrRIOR TO GPGUTING AND F AL INSPECTION. k <br /> gIGNED TITLE <br /> (DRAW-PLOT PLAN ON REVERSE SIDE "" <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> PPLICATION ACCEPTED BY 4W4,17 DATE <br /> 6mDDITIONAL COMMENTS: <br /> PHASE II GROUT INSF94ATION P 4AII INAL INSPECT N <br /> NSPECTION BY DATE INSPECTION BY//Z&", DATE ^„ <br /> 3/76 2M <br />