Laserfiche WebLink
'. SAN JOAQUINr LOCAL HEALTH DISTRICT <br /> '.. <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Cali <br /> Telephone: (209) 466-6781 <br /> APPLICATION, FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) i <br /> t to construct <br /> Application is hereby made to I inthe San Joaquin Local Health Distr. ct for a permi <br /> d. This applicaton s e oa quin Local Health District. <br /> compliance with San Joaquin' <br /> and/or install the work herein describe <br /> County Ordinance No.. 1862 and the Rules ,a6 Regulations of the Sa Joa <br /> l/1Z/P <br /> ; <br /> JOB ADDRESS/LOCATION , 5e_ CENSUS TRACT <br /> Phone VI —2:E�- <br /> Owner's Name C. �'� <br /> i <br /> City <br /> Address 2 0K <br /> License # Phone5l -,3 <br /> Contractor's Name <br /> TYPE OF WORK (Check) :. NEW WELL/ / DEEPEN '/ I RECONDITION I I DESTRUCTION I� <br /> PUMP INSTALLATION / / PUMP REPAIR '/ I PUMP REPLACEMENT /_7 <br /> Other Fri ioi fc7-�i n� �t <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> It TYPE OF WELL <br /> INTENDED USE <br /> CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Industrial <br /> Drilled Dia. of Well Casing <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> f Cathodic Protection Rotary Type of Grout <br /> r Disposal Other Other Information <br /> Geophysical ! Surf ace Seal Installed By: <br /> PUMP INSTALLATION: Contractor dl No, �c its <br /> H.P. a e� <br /> Type of Pump ° <br /> a <br /> PUMP REPLACEMENT: I / State Work Done <br /> PUMP .REPAIR• I State--Work Done <br /> fApproximate Depth �U " <br /> DESTRUCTION-t -WELL:" `--We-114Dfameter <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Californiapertaining to or regulating well'constxuction. Within FIFTEEN DAYS <br /> after completion of my work' on a new well, I will furnish the San Joaquin Local Health District a <br /> ruse.. The above <br /> WELL DRILLERS REPORT of thefwell and notify them before putting the well in <br /> information is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FxNAL INSPECTION. TITLE � "A •" <br /> SIGNED �z.t�i {DRAW PLOT PLAN ON REVERSE SIDE) <br /> '. FOR DEPARTMENT USE ONLY [[ <br /> PHASE T DATE <br /> �J <br /> I APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: pgE FIN ANSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> 77 2H <br />