Laserfiche WebLink
- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Y1601 E. Hazelton Ave . , Stockton►, Calif- <br /> CE <br /> alif.CE USE: � f <br /> . Telephone: (209) 466-6781 Permit No• 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 'J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 1 <br /> (Complete In Triplicate) permit to construct <br /> cation is hereby made to the San Joaquin Locallicalth District made inrco pliance with San Joaquin+ <br /> or install the work herein described. This app <br /> �t Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Y <br /> �►y r CENSUS TRACT <br /> / ADDRESS/LOCATIOVk__3L C/� <br /> Phone3 <br /> er's Name <br /> -t city — <br /> Addres <br /> License # 10q yphone3� <br /> Contractor s Name <br /> RECONDITION / DESTRUCTION /�7 T <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / PUMP REPLACEMENT I <br /> PUMP INST LATION / PUMP REPAIR <br /> Other <br /> SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK��SEWAGE DISPOSAL FIELD �-- <br /> CESSPOOL/SEEPAGE PIT OTHER, <br /> � <br /> T <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC DOMESTIC 'WELLCONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL ri CJ <br /> Industrial _ Cable Tool Dia. of Well Excavation Q) <br /> Drilled Dia. of Well Casing <br /> x Domestic/private Driven Gauge of Casing <br /> 7 Domestic/public <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Te of Grout <br /> Cathodic Protection Rotary Other Information <br /> Disposal Other <br /> Surface Seal installed B <br /> Geophysical <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter ----- <br /> Describe Material and Procedure » <br /> cal <br /> lth <br /> rict <br /> I hereby agree to comply with all� ans todoregegulating wellthe <br /> "construction.LoWithin aFIFTEEN tDAYS <br /> and the State of California pertaining <br /> after completion of my work on a new well, Ith mlbeforesh the San putting theowellninouse.HeThehabove <br /> WELL DRILLERS REPORT of the well District <br /> and notify <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND A FINAL INSPECTION. TITLE <br /> SIGNED RAW PLOT PLAN ON REVERSE SIDE <br /> 3 <br /> FOR DEPARTMENT USE-ONLY--- <br /> PHASE <br /> SE-ONLY--- <br /> PHASE I �- DATE �� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL 7--_INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE t 2' <br /> 101 <br /> INSPECTION BY <br /> DATE - <br /> 2M <br />