Laserfiche WebLink
1 <br /> SAN JOA "li LOCAL HEALTH DISTRICT M S Q `.5 <br /> FQF` OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. I.,/� Q-� <br /> -; Telephone: (204) 466--6781 Permit No. � f� . <br /> APPLICA4.TION FOR WELL CONSTRUCTION OR PUMP PERMIT f <br /> THIS PERMIT EXPIRES 1 <br /> YEAR FROM DATE ISSUED Date issued / - 7� <br /> (Complete In Triplicate) permit to construct <br /> Application is hereby made tothe San Joaquin Local Health District fora with <br /> and/or install the work herein described. This applicationthe. Sanis e.Joaquinin pLocal eHealth SDistrict <br /> County Ordinance No, 1862 and the and Regulation � <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone ---- , <br /> Owner's Name <br /> IleCity f <br />. Address <br /> License # Phone <br /> Contractor's Name <br /> 1 <br /> DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> TYPE OF'IWORK (Check) : NEW WELL / / PUMP REPLACEMENT I <br /> PUMP INSTALLATION ' PUMP REPAIR / <br /> Other :/ / <br /> � PIT PRIVY `- <br /> DISTANCE TO NEAREST: TANK SEWER LINES OTHER <br /> L F ' <br /> SEWAGEjDISPOSAIELD CESSPOOL/SEEPAGE PTT <br /> PUBLIC DOMESTIC WELD. — <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool Dia. 'of Well Excavation -- . <br /> 3Drilled Dia, of Well. Casing <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public Depth of Grout Seal <br /> Irrigation :1 Gravel Pack p <br /> Type of Grout <br /> Cathodic Protection i Rotary Other Information <br /> Disposal 1 Other <br /> ! Surface Seal Installed <br /> Geophysical B <br /> PUMP INSTALLATION: Contractor H.P. "'-w _____.. <br /> Type 1 of Pump <br /> PUMP-REPLACEMENT / T yState Work` Done <br /> / / State Work Done <br /> (.Pump .REPAIR: <br /> r 4 F ' '` Approximate Depth , <br /> DESTRUCTION OF WELL- <br /> DesDiameter __ <br /> Describe Material and -Procedure <br /> a { <br /> f I hereby agree to comply with all Jaws and regulations of the San 3oaquin Local Health Disuctiontrict <br /> and the ,State of California pertaining to or rellulatingshethecSant.�oaquin�LocalhHealth in TDi.strict <br /> f <br /> after completion of my work e anew well, I w <br /> ; WELL DRILLERS REPORT of the well and notowledify hemandbefore <br /> beliefputting <br /> l WILL CALL FOR AeGROUTThe <br /> INSPECTION <br /> information is true to the best of my kn g - -- <br /> PRIOR TO GRO INC AND A FINAL INSPECTION. TITLE <br /> SIGNED (DRAL�TPLOT ,PLAN.ON REVERSE SIDE) ------- <br /> r. %.,.r <br /> FOR DEPARTMENT USE:ONLY -f 7 <br /> PHASE I ` T <br /> .k DATE <br /> APPLICATION ACCEPTED BY � . . <br /> ADDITIONAL--COMMENTS: - --.• ''_ PHASE I/FIN INSPECTIO d <br /> PHASE II GROUT INSPECTION DATE — d <br /> DATE_ "INSPECTION BY <br /> INSPECTION BY 7 77 <br />