Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOR,OFFICE USE: Telephone: (209} x+66-6781 <br /> FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No• "� <br /> APPLICATIONF <br /> Date Issued 3 } <br /> THIS (Complete <br /> EXPIRES 1 YEAR FROM D ATE ISSUED 4 <br /> (Complete In Trip ## <br /> ication is made in compliance with San Jo quinti <br /> Application is Hereby made to the San Joaquin LocallHealth District for a permit to construs�r <br /> and/or install the work herein, described. This app ; <br /> Ordinance Na'. 1862 and.:the Rules and Regulations of the San Joaquin Local Health <br /> County J CENSUS TRACT <br /> JOB ADDRESS/LOCATION V Phone l <br /> Owner's Name f <br /> City cy V <br /> Address # Phone <br /> e 4� <br /> Licens . <br /> Contractor's Name �7 <br /> - DEEPEN / / RECONDITION, / <br /> DESTRUCTION /;T <br /> TYPE OF WORK (Check) : NEW;WELL PUMP REPAIR) / / P.UMP-g REPLACEMENT I T <br /> PUMP 'INSTALLATION <br /> other <br /> t � PIT PRIVY ' <br /> SEWER LINES <br /> ' DISTANCE TO NEAREST: /SEPTIC TANK /—dESSPOOL/SEEPAGE-PIT OTHER <br /> jSEWAGE�DISPOSAL FIELD- - PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATION <br /> INTENDED USE TYPE OF WELL k <br /> Cable �Tool;"'4 <br /> Dia. ofWell Excavation <br /> ,Industrial Drilled Dia. of Well Casing <br /> Domestic/private Gauge of Casing r <br /> Domestic/public Driven <br /> ( l am-- <br /> --Gravel-Pack- '"' Depth of,Grou•t- Seal <br /> Irrigation Rotar Type of Grout <br /> Cathodic Protection y - <br /> Other Other Information _ t <br /> 1 Disposal 5urface.xSeal" Installed B <br /> ____--Geophysical <br /> PUMP INSTALLATION: Contractor s H.P. <br /> Type of Pu <br /> mp E t <br /> PUMP REPLACEMENT-. / / State Work Done <br /> State Work Done <br /> PUMP .REPAIR: I/ �.nw, j <br /> Approximate Depth _ <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> ial ations of the ban Joaquin <br /> I hereby agree to comply with all laws ando�eregulating well "construction.L.oWithinaFIFTEENtDA S <br /> and the State of California pertaining to g <br /> ', after completion of my work on a new <br /> well, Ithemlbefvresputtingtheh the0an owellninouseHeThehabover �t <br /> WELL DRILLERS REPORT of the welland notify <br /> information is true to thefbest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR <br /> JN D A ,INAL INSPECTION. TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENTenE, ONLY '. <br /> PHASE IDATE .3 Z O 2 <br /> i <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHA5E III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY C'. DATE <br /> INSPECTION BY DATE <br /> ' , 1177 _. ' 2M <br /> 1-7A <br />