Laserfiche WebLink
4A J�i SAN JOAQUIN LOCAL HEALTH DISTRICT " <br /> "F'. OFF E USE: V601 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 Z �- S <br /> ' <br /> Co <br /> ( mplete In Triplicate) <br /> J APnlication 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 Joaquft <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br />! A Phone , <br /> Address &4 AJ <br /> City ' <br /> Contractor's Name License # ,l�Phone �( <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN '/? RECONDITION / DESTRUCTION /—f <br /> PUMP INSTALLA7�ION / PUMP REPAIR 1-7—Pump REPLACEMENT J <br /> ` Other E7 <br /> D];STANCE TO NEAREST: SEPTIC TANK SEWER LINES FIT PRIVY <br /> ;r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL�� <br /> INTENDED l TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> r " Industrial j <br /> Cable Tool Dia. of Well Excavation i <br /> Domestic/private Drilled Dia. of Well Casing ? <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Gis <br /> eopal � Other _ Other Information ' <br /> Geophhyysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor _ ': f .w <br /> Type of Pump ; <br /> H.P. <br /> PUMP REPLACEMENT: /X/ State Work Dane <br /> IMP 'REPAIR: /% State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure APProxitnate Depth <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 /> Health -T-- <br /> after completion of my work on anew 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-bes of..my oxledge. and belief. I WILL CALL -FOR A GROUT INSPECTION <br /> PRIOR OUTING AND A FINN E I N� <br /> SIGNE ITLE <br /> ._ <br /> {DRAW PLOT PLAN OIiC RSE SIDE <br /> PHA DEP TIENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE ' <br /> PHASE 11 GROUT INSPECTION PHA F AL IA1 PECTI <br /> INSPECTION BY DATE INSPECTION B <br /> DATE � <br /> ,E H ].426' Rev 1-74 <br />