Laserfiche WebLink
FOR- OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F 2601 E. Hazelton Ave'. , Stockton, Calif. <br /> 4 Telephone: (209) 466-6781 c <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. %Q <br /> THIS PERMIT EXPIRES 1'pY.EAR FROM DATE ISSUED <br /> � Date Issued', _� <br /> Application ism ereb (Complete In Triplicate) <br /> y made to the San Joaquin Local Health District for a <br /> and/or install the work herein described. This application is made in compliance with <br /> an Joaquin ! <br /> County Ordinance No, permit to construct <br /> 1862 -and the Rules and Regulations of the San Joaquin Local Health SDistrict. <br /> JOB ADDRESS/LOCATION,_ . <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone �, �z�_yL�� <br /> Address �©��� -. �!� <br /> Contractor's Name <br /> City Aor Com' <br /> License _ Phone33f3 <br /> TYPE OF WORK (Check) : NEW WELL <br /> DEEPEN /% RECONDITION i <br /> PUMP INSTALLATION ? PUMP REPAIR / / DESTRUCTION /? U <br /> Other /j / // PUMP REPLACEMENT /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK � � <br /> SEWAGE"DI-SPOSAL FIELD � . ,- <br /> ! CESSPOOL%SEEPAGE PIS' ER <br /> WELL PROPERTY LINE -- PRIVATE DOMES-ITC WELL �� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE,OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Domestic/private 1� Cable Tool Dia. of Well Excavation f <br /> Domestic DriY]edia, of We ' Casing <br /> /public Drive-a?" Gau <br /> Irrigation ,. & of Casing / <br /> Gravel Pack {� <br /> Cathodic Protection Depth of Grout Seal <br /> ► Rotarya f,•. T <br /> Disposal ,. ---YPe of Grout �' <br /> Geophysical Other , Other Information _fl <br /> i Surface Seal Installed B <br />'UMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P, , f <br /> UMF REPLACEMENT: ,-�/—// ':S tate Work-Donel <br /> UMP .REPAIR: <br />- ---�-� State Work Donee ` �i # <br /> S•TRUCTION OF WELL: Well Diameter <br /> DescribelfMaterial and Prbcedure, Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health istr <br /> id 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 welland notify them before putting the well in use. The above <br /> i ormation is true to the best of- my knowledge and belief. I WILL GALL FOR A GROUT INSPECTION <br /> IOR TO GRO ING AND A FINAL INSPECTION. <br /> GNED <br /> TITLE �,� <br /> (DRAW PLOT PLAN ON�REVE�RcvIDE)ASE I FOR DEPARTMEN <br /> PLICATION ACCEPTED BY <br /> DITIONAL COMMENTS: DATE 2 <br /> PHASE II GROUT INSPECTION <br /> N PHASE III/FINAL INSPECTION <br /> SPECTION BY DATE <br /> INSPECTION BYDATE -� <br /> E H,1426 1 <br /> X <br /> Rev. 1-74 <br />