Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: <br /> F <br /> M 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i Telephone: (209) 466-6781 permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR P <br /> F <br /> OR UMP PERMIT <br /> THISIPERMIT EXPIRES I YEAR FROM DATE ISSUE <br /> Date Issued �7 <br /> .120/ (Complete In Triplicate) <br /> Application is hereby made to ''the San Joaquin Local Health District for a permit to construct <br /> p application is made in compliance with San Joaquin <br /> and/or install the work herein described. This <br /> Count Ordinance No. 1862 andf� Rules and Regulations of the San Joaquin Local Health District. <br /> County � Ithe <br /> � NSUS TRACT <br /> 'JOB ADDRESS/LOCATION 3 <br /> 1 Phone <br /> Owner's Name <br /> City h <br /> Address3 �'� 3� <br /> License #/C.1� Phone <br /> Contractor's Name i <br /> RECONDITION f_1 DESTRUCTION I7 <br /> IT <br /> TYPE OF WORK (Check) : ` NEW WELL DEEPEN / :/ REPLACEMENT <br /> PURP INSTALLATION PUMP REPAIR PUMP <br /> Other,I0 <br /> 1 <br /> PIT PRIVY <br /> SEWER LINES OTHER <br /> DISTANCE TO NEAREST: SEPTIC'TANK CESSPOOL/SEEPAGE PIT <br /> SEWAGE�DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS \ <br /> INTENDED USE TYPE OF WELL <br /> Cable Tool Dia. of Well Excavation <br /> Industrial Drilled Dia. of Well Casing <br /> Domestic/private <br /> I ----r- Driven Gauge _of Casing <br /> Domestic/public 4 De th of Grout Seal <br /> Irrigation Gravel Pack p <br /> Rotary Type of Grout <br /> Cathodic Protection �- pther-lnrformation- <br /> _�. Other �---- <br /> Dispos',A1_ Surface Seal Installed B <br /> Geophysical <br /> pUMP INSTALLATION: Contractor ID H.P. /U <br /> l Type�of Pump <br /> State Work Done <br /> PUMP REPLACEMENT:.,-' I v <br /> k <br /> State Work Done <br /> PUMP REPAIR: - U I� <br /> Approximate Depth <br /> ]DESTRUCTION OF WELL: Well <br /> ial and Procedure <br /> quin Local <br /> agree to comply with all laws and regulations of the', Sastruction. WithitnaDistrict <br /> I hereby agr p <br /> FIFTEEN DAYS <br /> and the State of California pertaining to or regulating well ion <br /> after completion of my work on a new well, Ithemwill <br /> beforefurnish <br /> puttingSan <br /> the�wellni ouse.HeThehabove <br /> r�ct G <br /> WELL DRILLERS REPORT of the well and notify <br /> st of my kno ledge and belief. I WILL CALL FOR A <br /> information is true to the,beGROUT INSPECTION <br /> t PRIOR TO GROU G D A INSPECT TITLE 77-1 <br /> SIGNED W PLOT' PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 4&4z- <br /> 5_pLIcATION <br /> ACCEPTED BY ji C� � <br /> F ADDITIONAL COMMENTS: �A p F AL IN <br /> PHASE II GROUT INSPECTION INSPECTION' BY DATE U' <br /> INSPECTION BY DATE <br /> 3/76 29 <br /> F u 1126 Rev. 1-74 <br />