Laserfiche WebLink
SAN JOAQUIN LOCA: HEALTH DISTRICT <br /> i OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.S- 7964/ <br /> �. THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued i' 7� <br /> (Complete In Triplicate) <br /> _ication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ..;or install the work herein described. This application is made in compliance with San Joaquin <br /> inty Ordinance No. 1862 and the Rules and Regulations of the /San Joaquin Local Health District. <br /> ADDRESS/LOCATION CENSUS TRACT <br /> —!r's Name 6 � /� /,� i� Phone �^ <br /> Tiess Cityc�!/�cc�c. . .�z <br /> :ractor's Name License Ii2mo i.�one /7 <br /> �c <br /> OF WORK (Check) : NEW WELL / DEEPEN %/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION A</ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> 'ANCE TO NEAREST: SEPTIC TANK/ SEWER LINES PIT PRIVY <br /> SEWAGE DISP SO AL FIELD CESSPOOL/SEEPAGE PIT / 7 f OTHER <br /> PROPERTY LINE/PRIVATE DOMESTIC WELL _e<, PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> .. Industrial Cable Tool Dia. of Well Excavation <br /> y Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /2 <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> _ Cathodic Protection Rotary Type of Grout <br /> _Disposal Other Other Information <br /> Geophysical Surfaacce7 Seal Installed By: G <br /> M INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> IF REPLACEMENT: / / State Work Done <br /> REPAIR: / / State Work Done <br /> -RUCTION OF WELL: Well Diameter Approximate Depth <br /> .. Describe Material and Procedure <br /> -reby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> 'fir completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> .L DRILLERS REPORT the well and notify them before putting the -well in use. The above <br /> rmation is tr o e my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> aR TO GROUT DF A F AL 4SP9zIQ0.1 <br /> :NED TITLE <br /> -T - ^0 SIDE r: <br /> OR DEP VqMENT USE ONLY <br /> ,SE I 7 <br /> -,ICATION ACCEPT Y B —6L DATE 9-3d •J-{ <br /> TIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION IPHAS • I I/FI AL INSPECTION <br /> 'nECTION BY DATE p y 7 INSPECTION B DATE <br />