Laserfiche WebLink
��0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE:Y 1601 E. Hazelton Ave. , Stockton, Calif. <br /> t Telephone (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued-T-1 -11 <br /> In <br /> Application is hereby made to the San (Complete <br /> fora permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the. Rules and Regulations of the San Joaquin Local Health District. <br /> , JOB ADDRESS/LOCATION _�, 1rfJ CENSUS TRACT <br /> Owner's Name Phone ` - <br /> Address <br /> S <br /> City <br /> Contractor's Name ,- �c� � =-n License ,Phone <br /> C " y <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT- <br /> Other <br /> EPLACEMENTOther 1/ / <br /> DISTANCE TO NEAREST: SEPTIC °TANK SEWER LINES PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE — PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool <br />� � � <br /> Dia. of Well Excavation/ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing i= <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary <br /> . Type of <br /> yp Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> _. Surface Seal Installed B ': <br /> PUMP INSTALLATION: Contractbr +'' 'r <br /> Type of Pump <br /> .- <br /> PUMP REPLACEMENT:� /` State` Work Done <br /> PUMP 'REPAIR: /. :S.tate `Work Dane <br /> 'REPAIR:.­ ­ _....� - - - -- - i <br /> DESTRUCTION OF WELL: Well Diameter - f <br /> Approximate Depth <br /> Describe Material and Procedure <br /> A I <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. ,Within FIFTEEN DAYS <br /> after completion of- my <br /> rk on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL .DRILLERS REPORT .of the well and notifythem before <br /> putting the well. in;use. The above � <br /> informationis true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 4 <br /> TITLE <br /> r 11 (DRAW PLOT PLAN ON REVERSE SIDE)-- " <br /> ' R DEPARTMENT' USE ONLY <br /> PHASE I G1 � . <br /> APPLICATION ACCEPTED BY DATE b r� <br /> ADDITIONAL- COMMENTS: ; <br /> PHASE II GROUT INSPECTION PHASE3kI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY :DATEf- <br /> E H 1426 Rev. 1-74 1177 . 2M <br />