Laserfiche WebLink
a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI4 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7f-110 <br /> THIS PERMIT. EXPIRES 1 YEAR. FROM DATE ISSUED Date, Issued 2:c - <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. , 1862 acid t Rules. and Regulations of .the San Joaquin Local Health District. <br /> JOB ADDRESSfLIcIT47 , <br /> x CT <br /> Owner's Name Phone x � <br /> k Address / 1 d City <br /> e Contractor's Name License11angg �� <br /> r� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /_" <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other E/ <br /> - I <br />' DISTANCE TO NEAREST- SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL FIELD CE SPOOL/SEEPAGE PIT OTHER C <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> ('Domestic/private i Drilled Dia, of Well Casing ~ <br /> Domestic/public Driven Gauge of Casing <br /> l Irrigation s Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionI�Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed By: <br />.-PUMP INSTALLATION• <br /> Contractor _ I <br /> Type of Pump H.P. J1J <br /> _ � J <br /> xPUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: S� J <br /> / / State Work ]]one F <br /> DES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall 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 I <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a 3 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <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 FINALIINSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I S <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ' DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT PECTION PHAS I I/FI INSPEC ON <br /> INSPECTION BY DATE INSPECTION BY DATE - �8 <br /> E H 1426 Rev. , 1777 4 r "`v__�01 7�� -*�►- � ,��Q� b��7 7 - COA <br />