Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOTOFFI E USE: /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 Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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 /> ,FOB ADDRESS/LOCATION CENSUS TRACT <br /> f Owner's Name Phone <br /> Address r L city . <br /> Contractor's Name 0 / License # 3' 4hone /1 <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN /7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION / PUMP REPAIR Z-7 PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . -PIT PRIVY <br /> E SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL : PUBLIC DOMESTIC WELL \ <br /> k INTENDED USE TYPE OF. WELL CONSTRUCTION SPECIFICATIONS \� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing (� <br /> Domestic/public Drivers Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary .Type of`-Grout " - <br /> r Disposal Other, Other Information ' ' <br /> Geophysical Surface Seal Installed 'BY: <br /> PUMP INSTALLATION: Contractor C, <br /> Type .of Pump H.P. X7 <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP -.REPAIR: State Work Done <br /> `, DES;TRUCTION 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•bes - my kn a and belief. ' I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO gA0jTING AND A FINAL. I 0 . _� <br /> . P <br /> SIGNE - c�N ITLE <br /> -(DRAWPLOT PLAN FRSE SIDE <br /> FOR DEPARTMEN FUSE ONLY <br /> PHASE I ^R <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: J <br /> PHASE II GROUT- INSPECTION SE III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY . r. . DATE -' rl <br />