Laserfiche WebLink
ftSAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7d-//8. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 1 (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 Joao <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distrif <br /> JOB ADDRESS/LOCATIONn tocL CENSUS TRACT D 5 <br /> i Owner`s Name <br /> _fcpN41 n t_a rrwt Phone <br /> Address / (o i City <br /> Contractor's Name ec License 4f 3 7fThone y `; <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN <br /> /-7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION /% PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other/% <br /> DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL _ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia, of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> 7G Irrigation .! Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal t Other Other Information , <br /> Geophysical Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ryya 3 I#w 45 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR• 7 State Work Done <br /> pES,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 <br /> I 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 /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the bebt.of my-kno le gefand lief <br /> PRIOR TO ING AND FINALI I WILL CALL FOR A GROUT INSPECTION <br /> ON. <br /> SIGNED ITLE ��� A <br /> l LbT LAN ON SE SIDE <br /> PHASE I <br /> EPART T USE ONLY <br /> , %�'� i <br /> APPLICATION ACCEPTE DATE <br /> ADDITIONAL COMMENTS: ! <br /> PHASE II OUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BYDATE DATE 9 i <br /> _ INSPECTIONBY <br />