Laserfiche WebLink
FOR OFFI E USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date Issued - �27 <br /> APPlication is hereby made tthe San Joaquin Local Health District fora ermit <br /> and/or install the work herein described. This application is made in compliance <br /> uinwith San <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joa P to construct <br /> JOB ADDRESS/LOCATION ' q Local Health District.' r <br /> Owner's Name CENSUS TRACT � <br /> r <br /> Address Phone <br /> City 1 <br /> Contractor's Name � <br /> a <br /> License # 7 Phone <br /> TYPE OF WORK (Check.) : NEW WELL El- DEEPEN RECONDITION /7 DESTRUCTION /`7 , t <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> Other // / Pte' REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK _ <br /> SEWAGE DISPOSAL FIELD <br /> WER LINES PIT rnIVY <br /> PROPERTY LINE - PRIMATE DOMESTICSWELL/SEEP PUBLIC bOMESTIO WELL <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECTFIf'ATTONS <br /> Domestic <br /> Cable Tool Dia. of Well Excavation <br /> /private Drilled <br /> Domestic/public Dia, of Well Casing <br /> Irrigation �`-- Driven of <br /> of Casing <br /> Cathodic Protection Gravel Pack Depth of Grout Seal <br /> Rotary <br /> Disposal —�_ y Type of Grout <br /> Geophysical Other Other Information <br /> Surface Seal Installed P_ <br />'UMP INSTALLATION: Contractor <br /> Type of Pump <br /> UMP REPLACEMENT: iff State Work Done <br />[IMP-PA R: <br /> / / State Work Done <br />; TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereb a � <br /> y gree to comply with all laws and regulations of the San Joaquin Local Health District <br /> td the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />:ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />;LL DRILLERS REPORT of the well and notify them before <br /> formation is true to the best of m knowled putting <br /> the .well in use. The above <br /> IOR TO GROU TNG AND A FINAL IN E yION,knowledge and beliefI WILL CALL FOR A GROUT INSPECTION <br /> GNED <br /> (D W PLOT PLAN ON REVERSETLE SIDE) <br /> / — .o. <br /> ASE I <br /> FOR DEPARTMENT USE ONLY <br /> PLICATION ACCEPTED L <br /> a <br />)ITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> iPECTTON BY PHASE III FINAL INSPECTION <br /> /� <br /> INSPECTION BY DATE- ? 7 <br /> E H 1426T' <br /> Rev. 1-74 1177 nar <br />