Laserfiche WebLink
i . -SAN JOAg13IN L AL HEALTH DISTRICT <br /> li�di L i Hazelton Ave. $ Stockton, Calif. <br /> Fob OFF�E USE: Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> IDate Issued -3 7. . <br /> THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> is hereby made to the San Joaquin Local Health District for 6in ca Permncetwith nSan u3o quip <br /> ct <br /> Application Y described. This application Health Districi- �, <br /> and/or install the work herein <br /> County Ordinance No. 18b2 arid�the Rules and Regulations of the Sett Joaquin Local CT <br /> d CENSUS TRA <br /> JOB ADDRESS/LOCATTON <br /> Phone <br /> Owner's —4", AZ— <br /> Name PA <br /> Address - <br /> License ;, . Phone <br /> Contractor's Name ' <br /> I DESTRUCTION <br /> TYPE OF WORK (Check): NEW WELL "I_T EEPEN I/PUMP REPATRI I�T l PUMP REPLACEMENT 17 <br /> PUMP INSTALLAT / <br /> Other' / / <br /> SEWER LINES _- PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT �� OTHER <br /> SEWAGE_ DISPOSAL FIELD M_�_ PUBLIC-DOMESTIC WELL <br /> PROPERTY LINE � PRIVATE m `STIP .CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE ; TYPE OF WELL <br /> i _Cable Tool Dia. of Well Excavation <br /> Industrial Drilled 'Dia'. of Well Casing <br /> I Domestic/private - Gauge of Casing <br /> Domestic/public _ � Driven ,. h <br /> 1, Gravel Pack-' Depth of Grout Seal <br /> Irrigation Type of Grout <br /> Cathodic Protection Rotary , <br /> Other ,.:. Other Information <br /> Disposal ---- :Surfrace Seal Installed 8 <br /> I - <br /> ^Geophysical F <br /> ` PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> State Work Done <br /> PtIMi' REPLACEMENT:. �� , <br /> PUMP .REPAIR: /7' State Work Done <br /> Approximate Depth <br /> t DESTRUCTION OF WELL: Well Diameter <br /> i Describe Aiaterial and Procedure <br /> AYS <br /> I�hereby gree to comply <br /> with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regllfurnishating ethe cSanJoaquin•Local Health DWithin istrict <br /> ! after completion of my work on anew well, I wil <br /> r . the.well in.use..WELL DRILLERS REPORT of the well and notify them before puttingThe ab°ve <br /> and belief. I WTI;$ CAL FORA"GROUT INSPECTION <br /> information is true to-the'•best-af my""knowledge <br /> PRIOR TO GR TING 'AND A FTN INSPECTION. TITLE <br /> SIGNED DRAW !;E-T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY / ; <br /> PiiASE I DATE <br /> AppLICATION� ACCEPTED BY ' <br /> t ADDITIONAL COMMENTS: �'��' b r PHASE III INSPECTrri0i <br /> • PHASE II GROUT Ii35PECTION INSPECTION BY DATE <br /> INSPECTION BY DATE . <br /> 2M. <br />