Laserfiche WebLink
x / SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> FOF�'OFFICE USE: v 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> 1. Telephone': (209) 466-6781 <br /> APPLICATION F6R1WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS' PjbRMIT EXPIRES l'YEAR FROM..DATE :ISSUED Date :Iesued77, 3 7� <br /> e " <br /> Application ishereby`.made to 'the Saih Joaquin -Local 11ealth,'(Complete In Tri licatDistrict. for a ..permit :to=construct <br /> and/or install the work-herein described. This -application is;made.,'in,,,compiignce ,with $an. .Toaquin <br /> County Ordii�si�te`No. 18,62' and the `Rules and Regulations-,o the-Sas Joaquin La:cekl.Hcalth ,District. <br /> JOB ADDRESS/LOCATION :a ' <br /> Al <br /> t ;CENSUSJ TRACT.., w <br /> Owner's- Name <br /> Phone <br /> Address Cx <br /> y _ ..City .. i.. <br /> Contractor's Name <br /> Licease Phone ; <br /> TYPE OF WORK (Check): NEW WELL ' <br /> DEEP '/? RECONDITION..: DESTRUCTION 7 <br /> _ PUMP INSTALLATION PUMP REPAIR'/� PUMP REPLACEMENT <br /> Other /�/ . /7 <br />.DISTANCE TO NEAREST: SEPTIC TANK Ado/ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE-PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOME5TIC WELL�� <br /> INTENDED' USE' TYPE OF WELL CONSTRUCTION 5PECIFICATIONS <br /> industrial p Cable Tool Dia. of Well Excavation` � <br /> � Dotm:stic/private _ Drilled Dia. of,We11.,Gasing . <br /> Domestic/public Driveni <br /> Irrigation _ Gauge of Casing <br /> Gravel Pack Depth of. Grout, 'Seal <br /> Cathodic Protection Rotary Type of..Grout <br /> : Disposal Other Other .Information <br /> _Geophysical Surface Seal, Installed B <br /> PUMP INSTALLATION: ' Con'tr'actor <br /> Type .of. Pump. <br /> H.P. <br /> PUMP REPLACEMENT: . L/ State*Work bone's " <br /> PUMP '.REPAIR: Lf .State <br /> Work Done <br /> DES1RUCTiON OF WELL:. Well Diameter Approximate-Depth <br /> Describe Material and Procedure <br /> I hereby agree, to comply with all laws and regulations of the San Joaquin rL'ocal Health District~ <br /> and the State of California pertaining to or regulating well, construction. Within FIFTEEN DAYS <br /> after conll�letion 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:th�..well. in:use...'-The above <br /> information is true to the-best•of.my knowledge and belief. I WILL CALL FOR.A:'GROUT INSPECTION <br />'RIOR TO GROUTING AND A 'H+... AL INSPECTION. <br /> SIGNED <br /> TITLE <br /> ' <br /> �(�RAW PLOT PLAN ON REVERSE SIDE) v ' <br /> PHASE I �. FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> G DATE 7� <br /> ADDITIONAL COMMENTS: !�� - .. <br /> PHASE II• GR UT INSPECTION PHASE IIT FINAL INSPECTION <br /> INSPECTION BY ` DATE INSPECTION BY DATE !/ <br /> Eft-H'" <br /> .' u .. - <br /> W6 Rev. 1 iii <br />