Laserfiche WebLink
FOR OFFICE USE; , SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : ` <br /> (209) 466-6781 <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date Issued <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 Joaquin <br /> County Ordinance No. 1862 and Rules and Regulations of the San Joaquin Local, Health Distri <br /> JOB ADDRESS/LOCATION �D ct. <br /> 011 <br /> J CENSUS TRACT <br /> Owner's NameM <br /> L� <br /> Address Phone <br /> O <br /> r <br /> City A <br /> Contractor's Name 1/0 <br /> License Phone <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN /_IRECONDITION /'/ DESTRUCTION _ <br /> PUMP INSTALLATION '/— REPAIR / / PUI REPLACEMENT/_7 <br /> Other L/ <br /> DISTANCE TO NEAREST: SEPTIC TANK �* <br /> SEWER LINES pIT PRIVY< A <br /> SEWAGE DISPOSAL FIELD _51 �CESSPOOL/SEEPAGE PIT - tjA <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DO OTWELD <br /> INTENDED USE TYPE OF WELL <br /> 71 <br /> Industrial CONSTRUCTION SPECIFICATIONS,-' S <br /> � <br /> stic/private <br /> Cable Tool Dia, of Well ExcavationomeDrilled <br /> Domestic/public Dia. of Well Casing <br /> Irrigation Driven Gauge of Casing , <br /> �� Gravel Pack Depth of Grout S al ; <br /> Cathodic Protection otary Type of Grout _ 5 ��� "`•�- <br /> Disposal Other Other Information _ <br /> Geo p hys i c al--- --_-__ ---�— <br /> At <br /> Surf Seal Installed B { <br /> PUMP INSTALLATION: Contractor <br /> .� Type of Pump <br /> _ <br /> P. <br /> PUMP REPLACEMENT: / /-State Work Done" , .. ' ' r�, .1 <br /> E t , C r r ti F <br /> PUMP .REPAIR: State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter = <br /> i <br /> Describe Material and Procedure Appro mate D pth <br /> I hereby agree to comply with all laws and regulati ns ofthe 4San Joaquin Local Heal <br /> ic <br /> and the State of California pertaining to or regulating well 'cons'truction. Within FIFTE.ENtr t <br /> after completion of my work on a new well, I will furnish th"e San Joaquiif`Local Health District a } <br /> W L bRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> in ation is true to e <br />'RIOR N f TIO nowledge and belief. I`;WILL CALL FOR A GROUT INSPECTION 4 <br /> GROUPING AND <br /> SIG <br /> TITLE. f <br /> DRAW PL T PLAN ON REVERSE SIDE <br />'RASE I 0 FOR DEPARTMENT USE ONLY, G : <br /> APPLICATION ACCEPTED BY <br /> MDITIONAL COMMENTS: DATE <br /> PHASE It ROUT INSPECTION <br /> INSPECTION BY DATE P E /FINAL INSPE I I° <br /> I INSPECTION BY TE 4' <br /> d'1ti. / ^ APs f <br /> E H 1426 Rev. J74. +C7'—" 3/76 9m ` <br />