Laserfiche WebLink
a - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO)~ OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) .466-6781 <br /> APPLICA i#}TION FOR WELL .CONSTRUCTION OR PUMP PERMIT Permit No. 7zf2 0� <br /> e f' <br /> THIS .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 44 (Complete In Triplicate) <br /> Application is hereby made toy`the San Joaquin Local Health District for a permit to construct <br /> and/or install the work here;.n described. This application is made in compliance with San Joaquin' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner Phone s Name d �� <br /> Address 9 i City . <br /> Contractor's Name License # Phone <br /> a <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN' /'/ RECONDITION / / DESTRUCTION /-7 f <br /> PUMP INSTLATION / / PUMP REPAIR A(/ PUMP REPLACEMENT <br /> AL <br /> i <br /> Other f / <br /> - f <br /> DISTANCE 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Well Excavation R ; <br /> Domestic/private 1 Drilled Dia, of Well Casing _ y _ �►) <br /> Domestic/public,. ! . <br /> Driven= - Gauge of-Casing--- <br /> Irrigation # Gravel Packer Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> )Disposal Other Other Information <br /> Geophysical _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �-r'' H.P. <br /> ._. <br /> ,1 <br /> PUMP REPLACEMENT: / / State Work Done r <br /> Kok <br /> PUMP .REPAIR: / State Work Done <br /> DESTRUCTION OF WELL: Well .Diameter Approximate Depth <br /> Describe Material and Procedure <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 a <br /> j WELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> information is true to the best of In —k wl ge'"and�elief. I WILL CALL FOR A GROUT INSPECTION <br /> ` PRIOR TO G. G AND FINAL ON. C <br /> SIGNED f �' . - <br /> rDRAGd PLOT LAN ON R FRSE SIDE) <br /> s FOR DEPARTMENT USE ONLY <br /> # PHASE I - <br /> ' APPLICATION ACCEPTED BY DATE -OP-Z?, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT#INSPECTION PHASE III/FINAL INSPECTION � ; <br /> INSPECTION BY _ �. DATE= . <br /> 77 <br /> INSPECTION BY--""W DA E �'" " <br /> u 1_L96 Rpv. . l-74 <br />