Laserfiche WebLink
I JOAQUIN LOCAL HEALTH DISTRICT/—) <br /> FOR OFFICE USE: . i <br /> 6C`� '. Hazelton Ave. , Stockton Cal. <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 /> j . (Complete In Triplicate) F 1Ub Cop 7S <br /> Application -is hereby made to the San Joaquin Local Health District for <br /> a permit <br /> and/or install the work herein described. This application is made incompliancetwithnSan uJo <br /> -County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Equin <br /> JOB ADDRESS/LOCATION <br /> Owner's Name CENSUS TRACT <br /> . f�.Pr � / <br /> IN Phone 85 <br /> Address <br /> .,� City <br /> Contr'actor's Name � <br /> aM License t2 Phone <br /> TYPE OF WORK (Check) :. NEW WELL ' <br /> DEEPEN /_� /RECONDITION / DESTRUCTION /_ <br /> PUMP INSTALLATION'k/ PUMP REPAIR / / P <br /> Other ./ UMP REPLACEMENT /7 cQ <br /> i <br /> ' / <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> 4 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WALL <br /> INTENDED USE y.. TYPE OF WELL <br /> r `sIndustrial i CONSTRUCTION SPECIFICATIONS <br /> Domestic a `-- Cable ToolDia. of' Well Excavation <br /> .Domestic/private ii Drilled Dia. of Well Casing f <br /> /public Driven Gauge of Casing <br /> : ���Irrig'ation , -Gravel Pack <br /> Depth of Grout Seal t' <br /> Cathodic Protection Rotary Type ype of Grout <br /> Disposal Other <br /> Geophysical Other Information <br /> �' ---� <br /> Surface Seal installed $ <br /> �+ <br />' PUMP INSTALLATION: Contractor <br /> Type of Pump ,S+ <br /> H.P. <br /> PSP REPLACEMENT: L� / State Work Done <br /> PUMP '.REPAIR: <br /> P / State Work Done <br /> I ]ES•TRUCTION OF WELL: Well Diameter � <br /> Describe Material and Procedure Approximate Depth <br /> 001 <br /> I hereby agree to comply�11wit all. law and regulations o the San"Joa uin Local <br /> i <br /> a <br /> and the State of California pertainiconstruction. WithinFIFTEENt <br /> ld� ng to or regulating well ' <br /> DAYS <br /> after completion of my wo.rk, 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 <br /> n use. The above <br /> information is true to the best of my knowledge and belief.Putting ILL.CALL FORA GROUT INSPECTIONi <br /> 'RIOR TO GROU D k F <br /> SIGNED ION. , . <br /> 00 <br /> TITLE <br /> R. (DRAW PLOT PLAN ON REVERSE SIDE) 11 <br /> PHASE I � <br /> FOR DEPARTMENT USE ONLY ! 1 <br /> kPPLICATION ACCEPTED BY6 <br /> kDDITIONAL COMMENTS: FI DATE <br /> PHASE II. GROUT INSPECTION <br /> INSPECTION BY PHASE T /FINAL INSPECTION a <br /> ':'j DATE INSPECTION BY <br /> DATE�f�•� <br /> ;E H 3.426- Rev. 1'74 If77 - 2M <br />