Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DIST <br /> FOR-OFFICE USE: 1601 E. RICT 4 <br /> Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No., _ s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED <br /> ' Date Issued <br /> i (Complete In Triplicate) <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 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION IAI S <br /> OG K O N CENSUS TRACT <br /> Owner's Name 57d <br /> U a� Phone17' o -- <br /> Address �O 0 . <br /> 7-0 G City _4 CffTa/r/ <br /> Contractor's Name VC — <br /> License #� Phone ' _ /7 <br /> I <br />..TYPE OF WORK (Check) ; NEW WELL DEEPENa <br /> —PUMP <br /> 1-7DESTRUCTION /_7 � <br /> PUMP- INSTALLATION PUMP REPAIR / PUMP REPLACEMENT <br /> Other /%. -- /7 --� <br /> DISTANCE TO NEAREST: ,SEPTIC TANK, i ' <br /> JOO SEWER LINES PTT PRIVY - <br /> SEWAGE DISPOSAL. FIELD CESSPOOL/SEEPAGE FIT <br /> OTHER <br /> PROPERTY{LINE -PkIVATE DOMESTIC WEL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL '�.� <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool �` Dia. of We11 Excavation <br /> Domestic/private ! DrilledZQ <br /> Domestic/public Dia. of Well Casing S.. <br /> .! Driven Gauge.of Casing G , <br /> Irrigation Gravel Pack Depth of. Grout Seal <br /> Cathodic Protection O' <br /> �� Rotary Type of Grout ��iVToiY��`E <br /> Disposal Other Geophysical Other Information <br /> 4D � --�--- -.. _ <br /> Surface Seal Installed B O c <br /> PUMP INSTALLATION: lCont actor <br /> Type-of Pump'— ' P <br /> H <br /> _ . . <br /> G E" <br />?UMP REPLACEMENT: / / State Work;Done 1 <br />?UMP :REPAIR' State Work_ Done <br /> iES•TRUCTION OF WELL. Well Diameter <br /> 11jescribe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health Dis trict <br /> i <br />.nd the State of California pertaining to or regulating well construction. Within FIFTEEN DA S <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health Distriot 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 f <br /> 1IOR TO GROU NG AND A F. AL INSPECTION. <br /> IGNED � <br /> TITLE <br /> (DRAW LOT PLAN ON REVERSE SIDEre2l <br /> IA.SE I OR DEPARTMENT USE ONLY <br />?PLICATION ACCEPTED B r <br />)DITIONAL COMMENTS: L/ DATE <br /> P S I ROUT INSPECTIO <br /> JSPECTION BY PHASE III/FINAL INSPECTION <br /> BATE 2/ INSPECTION BY /` DATE <br /> r _ <br /> E H 1426 Rev. 1-74 H <br />