Laserfiche WebLink
t SAN JOAQUIN :LOCAL HEALTH DISTRICT <br /> FOh OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> : <br /> Tele hone <br /> , p (209) 466-6781 <br /> �. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-x5"334) <br /> THIS IPERMIT EXPIRES T YEAR .FROM DATi,'ISSUED , Date. Issued <br /> (Complete in Triplicate) .,. }. <br /> Application is hereby mhde to the San Joaquin Local Health District for .a:,per mit :to construct <br /> F sand/or install the work, herein described. This application is .made, in;,enmpliance with San Joaquin <br /> County Ordinance No. 1862 an`d -the Rules and Regulations of the. San,-Jgaquin Local Health: District. <br /> E�J'OB ADDRESS/LOCATION z 7Z ev.Zz fi7ej CENSUS TRACT <br /> Owner's Name Phone f <br /> Address ;! s City <br /> ' <br /> Contract`ors Name nef <br /> . � � License� .Pho �. <br /> TYPE OF WORK (Check)! NEW WELL//7--DEEPEN /? RECONDITION /_]` DESTRUCTIOW/7 <br /> AL <br /> PUMP INSTLATION Ii; - .PUMP REPAIR17/ 7 Pump REPLACEMENT <br /> . Other ET . <br /> DISTANCE TO NEAREST: `SEPTIC-TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER v <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELT, ��i <br /> a, INTENDED USE ; TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial / able Tool Dia. of Well ExcavationE <br /> _f.�mestic/private ,i, Drilled Dia., of Weli Casing. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack/ Depth of Grout Seal— <br /> Cathodic Protection Rotary Type of Grout .- <br /> Disposal Other Other Information <br /> Geophysical N� Surface Seal Installed' By• <br /> PUMP INSTALLATION: Contractor <br /> K s <br /> Type�of Pump H,P• <br /> PULP REPLACEMENT: - State Work Done t c <br /> PRIMP 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 /> rafter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERSREPORT of the well and notify them before putting.. the.-well. in:use..-, The above <br /> information is true to the•best-of• my­knowledge and belief. I WILL CALL FOR A GROUT..INSPECTiON <br /> PRIOR .TO GRO ING D AIIN I PECTION. l <br /> � SIGNED / ..'TITLE C � <br /> ". (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ _ ' _ DATE., "3!>-L6 <br /> ADDITIONAL CoMmENTS: <br /> PHASE II GROUT INSPECTION ]PHASE III INAL INSPECTION <br /> INSPECTION BY DATE S� INSPECTION BY DATE <br /> is <br /> E H 1426 r. Rev, 1-,7 4 • . <br />