Laserfiche WebLink
FOSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 F�;OFFICE USE: 1601 E. Hazelton Ave. <br /> Telephone: > Stockton, Calif. <br /> 6 <br /> APPICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7�-//7/JQ <br /> (complete In Triplicate} Date Issued , <br /> . <br /> Application is hereby made to the Sun Joaquin Local health District for a <br /> and/or install the work herein described. This application is made in compliance with <br /> County Ordinance Na. 1862 and the Rules and Regulations of the San jPermit to construct <br /> oagt�in Local Health SDistrictan �� <br /> JOB ADDRESSAOCATION <br /> Owner's Name <br /> CENSUS TRACT <br /> �. <br /> � Address Phone <br /> L <br /> - <br /> Contractor's Name City <br /> M <br /> License <br /> P TYPE OF WORK (Check): NEW WELL 'LZ;I�EEPEN '/_7 RECONDITION � DESTRUCTION /� <br /> Other /% /�W REPAIR ;/? PUMP REPLACEMENT /J <br /> DISTANCE TO NEAREST: -- <br /> SEPTIC TANK SEWER LINES _ <br /> SEWAGE DISPQSAI,FIELD gIT PRIVY _ <br /> PROPERTY LINE PRIVATE DOMESTIC SWELL SE PAGPUEBLIC MESTIOTHER <br /> C INTENDED USE TYPE OF WELL C WELL <br /> Industria- a��gble Took. CONSTRUCTION SPECIFICATIONS �I <br /> �lmestic/private Drilled Dia. of Well Excavation <br /> Domestic/public ---+ Dia. of Well Casing v <br /> Irrigation — Driven Gauge of Casing \ , <br /> Cathodic Protection "—"— Gravel Pack Depth of Grout Seal V <br /> ,Disposal. Rotary Type of Grout <br /> :,.,,_„—Geophysical ----- Other ------ Other Information <br /> Surface Seal Installed 'B j <br /> PUM------------- <br /> P INSTAI•LATIQN: Contractor <br /> Type of Pump ` <br /> { <br /> PUMP REPLACEMENT: A.P./ / State Work Done 1 <br /> PUMP :REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> T hereby agree to comply with all laws and regulations of the San .Joaquin Local Health � <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAY <br /> after completion of my work on a new well, I will furnish the San .Joaquin Local He District <br /> WELL DRILLERS REPORT of the well and notify them before S <br /> Information is true to the best of. Health District a <br />'RIOR TO GROU IN D A FINAL INSPECT Putting.. the .well. in.use... .The above <br /> my knowledge and belief. I WILL CALL" FOR A GROUT INSPECTION <br />'IGNED <br /> D W PLOT PLAN�&N �VER�TLE <br /> DE'RASE I FORDEPARTSE ONLY <br /> 1'P IL�C.ATION ACCEPTED BY <br /> DDITIONAL COMMENTS.-. DATE Z_31— <br /> PHASE II GROUT INSPECTION rt . ' <br /> NSPECTION 8Y DATE P SE I I F INSPECTION <br /> INSPECTION B ATE <br /> _E H 1426 Rev. 1-74 <br />