Laserfiche WebLink
C <br /> SAN-JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE SE: 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 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 s <br /> Owner's Name u Phone <br /> Address0 City <br /> Contractor's Name License 4 --Phone _ <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN'/_/ RECONDITION /W�// DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR �Z/ PUMP REPLACEMENT /_7 ` <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL 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 �} <br /> X. Domestic/public Driven Gauge of Casing __ - _ �• <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic, Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical - Surface Seal Installed By: <br /> PUMP INSTALLATION: _ y <br /> •Contractor gi+�� <br /> k Type of Pump ..n ,�i/ H.P. 7 1� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Donee► A ,� <br /> F <br /> DESTRUCTION 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 regulatfng -well 'construction. Within FIFTEEN DAYS i <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 i <br /> information is true to the best of my.. ;wledgean-dbeliefI WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G AND. A FINAL INS <br /> SIGNED .. _ ITLE <br /> D W <br /> TM <br /> L ON RE SE SIDE) -I �!7--77;1 <br /> OR DEPARTMENT.,USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASWIA/FlNa INSPECTIODY <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> kk <br /> I <br /> E H 1426 Rev. 1-74 3/76 2M � <br />