Laserfiche WebLink
. n SAN JOAQUIN LOCAL HEALTH DISTRICT Q S <br /> FO& OFFICE USE: 1601 E. Hazelton Ave. ,. Stockton, Calif. 157 <br /> Telephone: (209) 466--6781 I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �/ L <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 Di.strict. for a permit to construct <br /> and/or instal in described.. This application .is made in .compliance with San Joaquin. <br /> County inane �. l 6 a d .the Rules and Regulations;of .the . San Joaquin Local :Health District., <br /> JOE ADCICENSUS. TRACT <br /> Owner's Name AOi Phone <br /> Address City <br /> Con4actor's Name License ��� hone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION_/ / DESTRUCTION /-7 — <br /> PUMP <br /> ESTRUCTION /-7 —PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> -F0 fL46;6-r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> .PROPERTY LINE - PRIVATE 'DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia, of Well Excavation�� <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Informat on <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done l)v%A4-&*IL b ill <br /> PUMP -.REPAIR: / / 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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> information is true to the b st of my knowledge and belief. I WILL CALL F A GRO INSPECTION <br />; PRIOR TO OUTIN D A FI INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERS . SIDE) <br /> i OR MENT SE 0 Y /s U <br /> PHASE I G <br /> APPLICATION ACCEPTED B ' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE lo �l7 7 - INSPECTION BY. DATE <br /> 2M <br /> E H 1426 Rev. - I-74 - <br />