Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 114" 1601 E. Hazelton Ave. , Stockton, Calif. <br /> OFFICE USE:. y1,� �I r{� <br /> , Telephone: (209) 466--6781 Permit No. 1 D�' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued `(^�� <br /> (Complete In Triplicate) <br /> ct <br /> Application is hereby made to the San Joaquin <br /> Local <br /> District <br /> made inrcompliancea permit twithnSanu <br /> isJoaquin; <br /> Thisapplication <br /> and/or install the work herein described. <br /> County Ordinance No. 1862 and the Rules and Regulations of .the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2351,3t � ' _ CENSUS TRACT <br /> _ " <br /> Owner's Name ffi <br /> Phone <br /> City • ,-�®l'� . <br /> Address <br /> i <br /> License 4�,� . HCl hone � 0� <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPEN/} / RECONDITION / / <br /> DESTRUCTION I=T <br /> PUMP INSTALLATION I I rPUMP-"REPAIR PUMP REPLACEMENT / <br /> Other' / <br /> PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. OTHER <br /> SEWAGE DISPOSAL FIELD �---CESSPOOL/SEEPAGE FIT <br /> PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE llOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br />� INTENDED USE TYPE :OF WELL � <br />� Indtas-tt=rta3..",.._.'�-._--.�---•-•^-•,-_`C�b1:ewToor�'��ia-.=-of Wei-i-Exeavati-on ,� <br /> c Dia. of Well Casing <br /> Domestic/.p.ri,V ter Drilled <br /> Driven Gauge of Casing <br /> Domestic/public De th of Grout Seal (.}� <br /> Irrigation Gravel Pack4 P <br /> Rotar Type of Grout -� <br /> Cathodic Protection y Other Information' <br /> Disposal • Other ,_____[kP .-- Surface Seal Installed B : <br /> k Geophysical 'J 1 <br /> PUMP INSTALLATION- Contractor H.%F. <br /> Of. , TYpe.:�af Pump F. <br /> PUMP REPLACEMENT /`,/ State Work Done <br /> S a <br /> PUMP REPAIR: / / <br /> { State Work Done I a <br /> n F' ApProxi.mate_De.pj - <br /> DES-TRUCTION OF WELL: Well Diameter ` <br /> Describe Material and Procedure <br /> j <br /> l <br /> I hereby agree to comply with all laws and �ruction. Within <br /> eg� ulating welleeonstrJoaquin Local aFIFTEENDistrict <br /> and the State of California pertaining to or. g <br /> after completion of my work on a new well, 'I7hemlbfurnish <br /> puttingthe athe�wellninouse.HeThe,aboverict a <br /> WELL DRILLERS REPORT of the well and notify t <br /> information is true to the'.,best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECT <br /> PRIOR TO GROUTIN A�DA �FIAL INSPECTION. TITLE r <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY ` <br /> PHASE I _ DAT / 7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: A <br /> PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY 114- ,, {,,,+ --DATE <br /> INSPECTION BY DATE, 1 <br /> - - - . - -7 A <br />