Laserfiche WebLink
SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR.OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 n <br /> a 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 Aereby made+ to the San Joaquin Local Health District for a"permit to construct T <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 Distract. <br /> JOB ADDRESS/LOCATIONQ�'' LIG � l� CENSUS TtACT. i <br /> Owner's Name .. . <br /> Phone' f -,1"12 <br /> Address �'�` (r�p city : <br /> Contractor's Name , f License # 37" Phone "� D <br /> TYPE OF WORK (Check) NEW-WELL '/-7 DEEPEN '/- RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT ) <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 'S <br /> SEWAGE. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHE�I' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTI WELL' i <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS <br /> _ CAT ONS (� , <br /> - Industrial - Cable Tool' Dia. of Well Excavation <br /> a <br /> Domestic/private Drilled Dia. of Well Casing c <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 'T Other Other Information <br /> -Geophysical Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done A/& <br /> %J <br />` PUMP .REPAIR: /_7 State Work Done <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 LocalHealth istrict <br /> and the State of California pertaining to or regulating well'-construction. Within FIFTHEN. 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 /> R <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AND FINAL,-INSPECTION. <br /> SIGNED', TITLE t�64 <br /> tz <br /> (DRAW PLOT PUN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY DATE �}o?5-7� <br /> ' . <br /> iADDITIONAL COMMENTS: <br /> PHASE II GRO T NSPECTION PHASE II /FT AL INSPECTI N <br /> INSPECTION BY ATE INSPECTION BY o 1ATE. <br /> E H '1426 Rev. 1-74 �� :7 y <br />