Laserfiche WebLink
# SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' y Stockton Calif. <br /> FOE �OFFICE USE: 1601 E. Hazelton Ave. , , <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP HERMIT Permit No. 7-/7 ja j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued r7�: <br /> (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 CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> icense Phone <br /> Contractors Name. � -- - <br /> TYPE OF WORK (Check)NEW WELL DEEPEN / RECONDITIQN /_/ DESTRUCTION <br /> PUMP�INSTAIL-ATZON /-�/ PUMPuREP�riR''/-/-- PUMP'-REPLACEMENT-.-_-/� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES P-IT_.PRIVY <br /> SEWAGE DI'SP S FIELD--------- CES P OL/SEEPAGEP PIT 0_THER = <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL � �. F PUBLICa DOMESTIC WELI, <br /> GTYPE OF-,WELL CONSTRUCTION SPECIFICATIONS ; ; <br /> %-'INTENDED _USED;..; j <br /> 1. IndustrialT '$` L----Gable J;oo1.tj. Dia. of Well. Excavation c 1 � r i <br /> E Domestc/p'riva;te Drilled ' Dia. of We11 Casing <br /> Domestic/publi'c��.,,,: =Driven Gauge of {Cas3ngj i <br /> �I gat on �' Gravel Pack Depth of ;Gr6d-� Seal "" 4 <br /> CathodicAProtectioii `Rotaty. Type of Groin. <br /> Disposal '. Other J 's,.* • -- her Information <br /> Geophysical Surface--S al Installed�B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / .-/ $ State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 1, Approximate Depth 3�- \_ <br /> Describe Material and Procedure <br /> ` I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and 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 thest of my. knowledge and belief. I WILL L FOR A GROUT INSPECTION <br /> PRIOR TOG G A Fla' 1I RECTION. <br /> SIGNED TITLE 1 <br /> D W PL T' PLAN ON REVERSE SI } -1 � <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> G APPLICATION ACCEPTED BY e- DATE - -7 <br /> ADDITIONAL COMMENTS: ; PHASE III/FINAL INSPECTI N <br /> PHASE II GROUT, INSPECTION� <br /> INSPECTION BY DATE INSPECTION BY �', _ DATE Jjl <br /> 376 2M <br /> r E H 1426 Rev. 1-74 <br />