Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOL� ,OFFICE USE: 16.01 E. HaxelCon Ave. , Stockton, Calif. <br /> Telephone: {209} 466-6781 G }� i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. f' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATVIISSUED . Date Issued <br /> ] {Complete In Triplicate} {� M <br /> Application is hereby made toithe San Joaquin Local Health District for a permit to construct =:;;: <br /> and/or install the work herein described. This application istmade in compliance with San Joaquin � <br /> County Ordinance No. 1862 andithe Rules and Regulations of the€ 5an Joaquin Local Health.District• <br /> JOB ADDRESS/LOCATION r CENSUS TRACT <br /> i, Phone3^ <br /> Owner's Name <br /> Own <br /> s11 s City l <br /> Address G p� <br /> License # -Phone- ' <br /> Contractor Name <br /> TYPE OF WORK (Check) : NEW WELL / 7 DEEPEN / RECONDITION �� DESTRUCTION <br /> ��T <br /> PUMP INSTALLATION/ / PUMP REPAIR'//II PUMP REPLACEME I <br /> Other E7 , <br /> , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/S€EEPAGE PIT .y� OTUR <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WE L� `\ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPRCIFZCATIONS <br /> Q <br /> Industrial , Cable Tool Dia. of Well. Excavation ' <br /> ate Drilled Dia. of Weil Casing J ' <br /> Domestic/privt, Gauge of Casing <br /> Driven <br /> Domestic/public <br /> Irrigation Gravel Pack Depth of Grout Sea1,< <br /> Rotary Cathodic Protection r �' �� - y Type of Grout <br /> .yY�y F . <br /> ---�--• ,Other —Other. Information <br /> Disposal -_ ...��. r , — . .; <br /> Geophysical = s f Y. �•` 5 �Siirface Seal Installed B <br /> PUMP INSTALLATION.- •Contractor V H.P. � <br /> t ,Type' of� Pump , <br /> ,-, L <br /> ,., i <br /> State Work Done <br /> E PUi+� &�,,_, <br /> REPLACEMENT 1 ; ' i <br /> PUMP .AFFAIR: State Work Done <br /> + Approximate Depth ,., ��'. <br /> DES-TRUCTION 'OF WELL: i Well` Diameter <br /> '-Describe Material and Procedure 9. r <br /> I 'hereby agree to comply with all lams and regulations of Che .San Joaquin Local Health District <br /> Califrnia pertainin <br /> and the State- -of gto or regulating welll'construction. i Within FIFTBR�1 DAYS <br /> { after completion a my work on: a new well, I will furnish the San Joaquin Local Health District a <br /> WELLDRILLERS REPORT of the well and notify them before putting the.wel', id use• The a#ove <br /> 3 information is true to the.best of my knowledge and belief. Ell WILL CALL FOR A GROUT I5P8CTI4N; <br /> s PRIOR TO UTING FIN ISP ION. I�TITLE <br /> SIGNERF D W P PLAN ON RSE SIDE <br /> FOR DEPARTMENT USZONLY <br /> PHASE I 4 ':DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMONTS: PHASE FIN INSPECTIONi '.- . <br /> PRASE II GRO NSPBCTION DATE �� v <br /> INSPECTION BY E <br /> INSPECTION BY <br /> 3'76 2M <br /> "E H 1426 Rev. ].74 <br />