Laserfiche WebLink
f �� SAN JOAQUIN LOCAL UEALTH DISTRICT <br /> t FOE OFFICE TjSE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 v <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. <br /> 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) _ <br />+ Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 18.62 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION <br /> •' o s 6NUS CT <br /> Owner's Name S '� <br /> Phone <br /> Address <br /> i City j � <br /> Contractor's Name <br /> t r <br /> i �nrc License �� � Phone <br /> ,1 <br /> TYPE OF WORK (Check} ;r. NEWDEEPEN / J 'RECONDITION'/`J' sTRUCTTON <br /> PUMP INSTAL ATION PUMP REPAIRNT/ PUMP REPLACEME /_7 <br /> Other /% — 0. if <br /> DISTANCE TO NEAREST: SEPTIC TANK f *�,_-�SEWER LINES � - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> PROPERTY LINL&2''�RIVATE DOMESTIC WEL14224 PUBLIC DOMESTIC WELL I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ` Cable Tool Dia, of Well Excavation �� r <br /> Domestic/private t Drilled Dia, of .Well Casing � I <br /> Domestic/public ! Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection { Rotary Type of Grout <br /> -,Disposal _ 1 Other <br /> Geophysical . Other Information <br /> �� <br /> ��- <br /> Surface Seal--Installed By:-- <br /> PUMP <br /> :PUMP INSTALLATION: ContractorrdN <br /> Type of Pump , <br /> _ H.P. I <br /> PUMP REPLACEMENT / / State Work Done <br /> PLTW ,.REPAIR: / / State Work Done j <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withall 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 work onla new well, I will furnish,. <br /> the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and n ify them before putting the wel_l. in use. The above <br /> information is true o, the est f nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR GR A FI P ON. j <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I , <br /> FOR DEPARTMENT USE ONLY <br /> `'rt �.��� ' <br />�PPLICATIW ACCEPTED-'BY DATE <br /> WDITIONAL COMMENTS; <br /> ko <br /> PHASE II-GROUT INSPECTION PHAS I I/FINAL INSPECTION <br />[NSPECTfON BY DATE INSPECTION BY DATE . <br /> E H 1426 Rev. 1-74 G>_7!., 2M j <br />