Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT 1� _ �A11-1 <br /> OF OFFICE USE: 16x1 E. Hazelton Ave. , <br /> Stockton, Calif. <br /> Telephone: (209) 466-6781 Permit No. k <br /> y' <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 /> b made to the San Joaquin Local Health' District inrconpliancermit twith SanJoaquin, <br /> Application is hereby scribed. This application i <br /> and/or install the work herein de <br /> ' once No. 1862 and -the Rules and Regulations of the San Joaquin Local Health District- <br /> County <br /> istr ct. ' <br /> County Orden <br /> CENSUS TRACT } <br /> JOB ADDRESS/LOCATION <br /> A <br /> Owner's Name 0 Phone <br /> city <br /> Address .. ^� � ( 6 Phone 3 '30 <br /> License <br /> Contractor's Name <br /> RECONDITION / DESTRUCTION / <br /> TYPE OF WORK (Check) : NEW WELL I DEEPEN /�/ p REPLACEMENT I7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / <br /> Other / / <br /> SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTICiTANK CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> :TYPE OF WELL N <br /> INTENDED USE <br /> t Cable Tool Dia. of Well Excavation <br /> Industrial — � Drilled Dia. of Well Casing <br /> Domestic/private � Gauge of Casing \ <br /> Domestic/public Driven <br /> of Grout Seal <br /> Gravel Pack Depth <br /> Irrigation } <br /> Rotary Type of Grout 1 <br /> Cathodic Protection other <br /> Other ��_... Other Information <br /> Disposal Surface Seal Installed B <br /> Geophysical <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> _f <br /> PULP REPLACEMENT: / /I State Work Dane <br /> i <br /> PUMP .REPAIR: / /� State Work Done , <br /> Approximate Depth �� ( <br /> DESTRUCTION OF WELL: Well Diameter �/LSP/'�rrv�- <br /> Describe Material and Procedure <br /> cal i <br /> rict <br /> I hereby agree to comply with all laws and reglulating wet.l'construction.� uation f the SanLnWithinaFIFTEENtDAcS <br /> e <br /> and the State of California pertaining to or g <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> he <br /> above <br /> WELL DRILLERS REPORT of the well and notify them ndfband I WILL CALL FOR Are putting the well in ee <br /> GROUT INSPECTION <br /> information is true to''*tf16 best of my knowledge <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. TITLE <br /> SIGNED (DRAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' P. <br /> DATE + <br /> 4 APPLICATION ACCEPTED BY o <br /> f ADDITIONAL COMMENTS: PH E I ./F NAI, INSPE TION <br /> PHASE II GROUT INSPECTION INSPf GTION BY DAT <br /> INSPECTION BY DATE <br /> k 2M <br />