Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone. (209) 466-6781 S <br /> APPLICATION FOR WELL CONSTRUCTION C3R 'UMP PERMIT Perinit �N6. <br /> J-11 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DaterIssued <br /> (Complete In Triplicate) <br />'•Appli.cation is hereby made to the San Joaquin Local llealth. 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. i <br /> JOB ADDRESS/LOCATION ��� � � /� • � CENSUS TRACT $ <br /> Owner e s Name v Phone q/, q •l 7 7 <br /> Address City <br /> Contractor's Name cense V-fqW Phone a <br /> TYPE OF WORK (Check)i NEW WELL / E PEN '/-7 RECONDITION /-7DESTRUCTION f7 <br /> PUMP INSTALLATION / PUMP REPAIR /� PUMP REPLAcm:ENT 17 _ <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 A----Mle. Tool Dia. of Well Excavation12 <br /> 4---IYo-me s tic/private Drilled Dia. of,We'll Casing <br /> Domestic/public Driven-" Gauge of Casing 1 <br /> ,Irrigation Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout �A C& <br /> Disposal ' Other Other Information <br /> Geophysical Surface Seal Installed B . �i <br /> PUMP INSTALLATION: Contractor d <br /> Type of Pump <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 /> ' f <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Districts . <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 <br /> , ;WELL DRILLERS REPORT of the well and notify them before putting. the .well. in.use.. The above <br /> i information is true to the•best•of my knowledge and belief. I WILL CALL FOR A "GROUT INSPECTION <br /> PRIOR TO GRO TIN AND A FIN SPECT ION. <br /> SIGNED TITLE q` <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE / 7 <br /> ADDITIONAL COMMENTS: 1 <br /> P I--QROUT INSPE ON PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE J -r INSPECTION BY �L DATE -="- <br /> 19 H 1426 Rev. 1-74 R' 1-74 2H.,,' <br />