Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE �e4e1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> (Complete In Triplicate) <br /> Application is Aereby 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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name � �� � Phone ��•�-- <br /> Address City <br /> + Contractor's Name License # Phone <br /> .)3T7ff' <br /> ' a <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/_/ RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION// PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other'/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITiFPRIVY M <br />{ SEWAGE DISPO AL FIELD .CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool _.Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing u <br /> Domestic/public Driven Gauge of Casing _ fs�� <br /> i <br /> Irrigation Gravel Pack �_Depthvof Grout Seal <br /> Cathodic Protection Rotary Type of Grout , 1(. <br /> Disposal Other Other Information <br /> Geophysical ,F Surface Seal .Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type'of Pump H.P. <br /> F ' <br />[ PUMP REPLACEMENT: / / State Work Done <br /> li PUMP .REPAIR: / f State Work Done <br />' DES-TRUCTION OF WELL: Well Diameterde Approximate Depth <br /> Describe Material and Proce/17e <br /> YW <br /> I hereby agree to comply with all laws and regula 1 o the San Joaquin Local Health District . <br /> Wand the State of California pertaining to or regul n well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I wit fu ish the San Joaquin Local Health District a <br />' WELL DRILLERS REPORT of the well and notif th b o e putting the..well in use. The above <br /> information is true to the best of my kno 1 elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND NAL I CT ION. <br /> SIGNED .fTITLE i <br /> (DRAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 6 --/u -.-,>,7 INSPECTION BY DATE 4 - 10 -11, <br /> E H 1426 Rev. 1-74 1177 2M j <br />