Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT w,�S <br /> FORT OFFICE SE.: . <br /> 1601 E. Hazelton.Ave-. , Stockton, Calif: <br /> Telephone: (209) 466-6781 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> /�-/----- <br /> --3a 7V <br /> � .. Date Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) a permit <br />€ Application is hereby made to the San Joaqu:iny5occallica th District <br /> made inrcompliancetwithnSanuJoaquin' <br /> and/or install the work here"in described, T PP <br /> County Ordinance No. 1862 and the -Rule's and Regulations of the. 5an Joaquin Local Health District. <br />[[ <br /> CENSUS TRACT <br /> JOE ADDRESS/LOCATION 7 r s f v P <br /> Phone - <br /> Owne r's Name pLU <br /> Cityo aa! <br /> Address ! .� O <br /> if License #; Phone <br /> Contractor's Name s't� <br /> ' TYPE OF WORK (Check) : NEW WELL / / DEEPEN .f / RECONDITION DESTRUCTION <br /> [INSTALLATION / .-/ PUMP REPAIR 11:7-: <br /> PUMP REPLACEMENT / <br /> PUMP ii _ <br /> Other / 1 <br /> - .PIT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PRIVY OTHER rn <br /> SEWAGE DISPOSAL- FIELD CESSPOOL/SEEPAGE PIT ;\ <br /> PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' , <br /> CONSTRi?CTION SPECIFICATIONS �( <br /> INTENDED USE �TYPE OF WELL Cable Tool t Dia. of Well Excavation <br /> Industrial <br /> Drilled , „ Dia. of Well Casing <br /> Domestic/private Drivei.n - Gauge of Casing <br /> Domestic./public , , Depth of Grout Seal <br /> . -5 Gravel Pack P <br /> irrigation Type of Grout . <br /> Cathodic Protection Rotary Other Information <br /> ]Disposal N ,; . `Other ! <br /> Surface Seal <br /> -Geophysical Installed B <br /> PUMP INSTALLATION: .Contractor H.P- <br /> Type of Pump <br /> PUMP REPLACEMENT: /�/ State Work Done S <br /> f PUMP REPAIR: <br /> � State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well <br /> rial and Procedure <br /> I hereby .agree to comply <br /> with all laws and regulations of the San JoaqDistrict <br /> uin Local Health <br /> t and the State of California pertaining to or will Ring hethecSantJoaquin. Within FIFTEEN <br /> AYS <br /> LocalHealthDistDrict <br /> 4 after completion -of my work on a new well, above <br /> WELL DRILLERS REPORT of the well and notify <br /> knowthem <br /> before <br /> ILL <br /> ledgeandbelief. I putting CAI,.. FOR A GROUT eINSPECTION <br /> information is true to the best of my g <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. � TITLE <br /> ir <br /> SIGNED <br /> (DRA 4.1110 -PLAN ON REVERSE SI4E _..." ' <br /> - <br /> � s FOR DEPARTMENT USE ONLY <br /> PHASE DATE - d <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE I I/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY it DATE <br /> ? <br />