Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT W, �a <br /> FOT .OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9.s- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued(Complete In Triplicate) <br /> 3�Application is hereby made to the San Joaquin Local Health District for a permit to onstruct <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 Regulat one-of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT - <br /> Owner's Name - Phone ' ! <br /> .�. .,. - f <br /> Address <br /> -... - -- City a <br /> Contractor's Name License <br /> Phone <br /> TYPE OF WORK (Check): NEW WELL , -? DEEPEN/7, RECONDITION 1-7 ESTRUCTi N <br /> PUMP INSTALLATION/ / PUMP REPAIR/� PUMP PLACEMENT J <br /> Other <br /> DI5TANCE Tfl NEAREST: SEPTiC TANK SEWER LINES FIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVAT DOE MESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ..! <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout i <br /> Disposal - Other Other Information a <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT L/ State Work Done <br /> PUMP ,REPAIR: <br /> /7 .State Work Done . <br /> _ LG <br /> DESTRUCTION OF WELL: Well Diameter 2� ��� � <br /> Approximate Depth /tea <br /> Describe Material and Procedure .01 <br /> �--•�/ <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District k <br /> and the State of California pertaining to or regulating well ''constructi.on, Within FIFTEEN DAYS # <br /> after completion 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. the..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 GROUTTITra AMD A V.1,11 AL INSPECTI <br /> 5IGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SID9) " - - '- <br />?HASE I FOR DEPARTMENT USE ONLY <br /> UTLICATION ACCEPTED BY <br /> WDIT.IONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION ,,. <br /> INSPECTION BY P -. - F AL- INSPECTIO —---� ! <br /> DATE INSPECTION BY DATE <br /> E H 1426 Ran_ 7.-'9/. _ - <br />