Laserfiche WebLink
y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORxQFFICS USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone:: <br /> p (ZO9) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITPermit No. -410 <br /> yy6636 9� <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> _ 1 <br /> ,TOB ADDRESS/LOCATION V CENSUS TRACT � <br /> Owner's Name Phone <br /> .Address 1 City <br /> Contractor's NameLic asePhon � . <br /> TYPE OF WORK (Check): NEW WELL '/17--DEEPEN -/7 RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /�PUMP- REPAJ 17 PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT/)PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL"2�# PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> Industrial L---Cable Tool f Dia. of Well Excavation <br /> domestic/private Drilled t I(Dia:}.of Well Casing04, <br /> Domestic/public Driven Gauge 'of ,Casing <br /> Irrigation Gravel Pack De th of+G out�Seal <br /> p _? a . <br /> Cathodic Protection Rotary w Type,of_Grout <br /> Disposal Other Other Information ' t <br /> -Geophysical �"" <br /> Surface Seal Installed B <br /> � e <br /> PUMP INSTALLATION: Contractor 0 � <br /> Type. of Pump - H.P. <br /> P F_ <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR-: /7. . . . . <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San .Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..well in.use.. ,The above i <br /> information is true to the-best-of"my..knowledge and belief. I WILL CALL FOR A 'GROUT INSPEC ON <br /> PRIOR TO GROUTING AND A FINAL INSP N. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY ff <br /> PHSE I ?b <br /> APPLICATION ACCEPTED BY C DATE " /o <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE [ ?` INSPECT-ION BY DATE ' ? ' <br /> Piz 11.14 <br />