Laserfiche WebLink
FOR OFFICE ,USE,: ' SAN JOAQUIN LOCAL.. HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No:7�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �J (Complete-In Triplicate) Date Issued �7 <br /> APPlication is hereby made to the San Joaquin Local Health Dist <br /> and/or install the work herein described. This a rict for a permit to construct <br /> County Ordinance No. 1862 and the Rules and Regulationstofnthe ans madeJoaquinpLocal ealt HeSan Joaquin <br /> lth District. <br /> JOB ADDRESS/LOCATION <br /> Owner's CENSUS TRACT Name G � - <br /> f Phone — V;lb-� <br /> Address � � �' � <br /> Contractor's NameCity <br /> License # <br /> Phone <br /> TYPEOFWORK (Check) : NEW WELL DEEPEN _ <br /> / /x RECONDITION /_% DESTRUCTION /-7 <br /> PUMP INSTALLATION O PUMP-REPAIR / / PUMP REPLACEMENT <br /> Other / / /-7 p <br /> DISTANCE, TO NEAREST: SEPTIC TANK <br /> SEWAGE DISPOSAL FIEZDWER LINES PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINED PRIVATE DOMESTIC WELL 'S OTHER <br /> INTENDED USE TYPE OF WELL PUBLIC DOMESTIC WELLW�� <br />�_ Drilled <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> /"Somestic/private L=-- <br /> lTool Dia. of Well Excavation <br /> /public <br /> Domestic Drilll ed Dia. of Well Casing1� , <br /> Driven <br /> _ Irrigation. Gauge of Casing Gft <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection — <br /> Rotary <br /> Disposal Type of Grout <br /> Otherc� <br /> Geophysical Other Information{ y <br /> Surface Sea] Installed B <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> _ H.P. <br />?UNP REPLACEMENT: State Work Done <br />'UMP :REPAIR: <br /> State Work Done { <br /> ESTRUCTION OF WELL: Well Diameter , <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Heal <br /> nd the State of California pertaining to or regulating well "construction, Within FIFTEENtrict <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the- well in use. The above <br /> nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> tIOR TO GROU,ZING AND A FINAL INSPECTION. <br /> IGNED " <br /> .�� �• TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)ZI <br /> `- <br /> 1ASE I FOR DEPARTMENT USE ONLY <br />'PLICATION ACCEPTED BY <br />)DITIONAL COMMENTS; DATE <br /> . PHASE II GROUT INSPECTION <br /> ISPECT,ION BY- DATE PHASE III/FINAL INSPECTION <br /> INSPECTION BY W< DATE ,oA -,,4-7 -7:-2 <br /> E H 1426 - <br /> *� ev. 1-74 <br />