Laserfiche WebLink
SAN JOAQUIN LOCAL .�'EALTH DISTRICT <br /> 'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ~--'� Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP �PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE *ISSUED Date Issued f^.Z <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Joaquin� <br /> and/or install the work herein described. This application is made in compliance with San <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone � a n�a <br /> Owner's Name �� . <br /> ,f <br /> City <br /> Address57 <br /> License # '.2.0 7 Phane ;j 9 <br /> Contractor's Name <br /> TYPE OF WORK (Check)-. NEW WELL 17 btEPEN 'l7 RECONDITION l_aT DESTRUCTION <br /> __ f7 1 <br /> 4 PUMP INSTALLATION .,/_/ PCTMP REPAIR'/ PUMP <br /> " <br /> »jOther <br /> DISTANCE TO NEAREST:v_SEPTIC TANK SEWER'� INES PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> S$EWAGE DISPOSAL FIELD +, PUBLIC DOMESTIC WELL <br /> PROPERTY v1INE PRIVATE DOMESTIC <br /> WELL'-�--- <br /> INTENDED USE TYPE`,OF WELL t , o7r � CONSTRUCTION SPECIFICATIONS <br /> ai_; <br /> Industrial ;'ti � Cable Tool. FDia. of Well Excavation \ <br /> Domestic/private ,^ Drilled Dia. of Well Casing <br /> Driven Gauge of Casing <br /> Domestic/public <br /> Gravel Pack Depth �6f. Grout Sea <br /> Irrigation % l. <br /> Cathodic Protection Rotary Type,of Grout <br /> er a � h Information <br /> Disposal Oth <br /> Geo h sic '� - Snrf4ce Seal Installed By, <br /> PUMP INSTALLATIO a Contractor N `'" H.P. <br /> Type of Pump <br /> y{y k <br /> i PUMP REPLACEMENT: . / State Work Done <br /> /--I'S to <br /> € PI�MP-�.-REEAIIt• / to Work 'Done ^- <br /> - Approximate Depth <br /> T}ES-TRUCTION OF WELL: Well'.Diame tez — <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Viand 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 /> 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 my-knowledge and belief. ' I WILL CALL FOR A 'GROUT INSPECTION <br /> rPRIOR TO GROUTING AND A FINAL INSPECTION. - <br /> rSIGNED ) -' � TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE S`� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: F x ------------ <br /> PHASE III FINAL INSPECTION <br /> PHASE II. GROUT .INSPECTION DATE /! <br /> INSPECTION BY DATE _ INSPECTION; l <br /> 4 2M <br />