Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOIrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 x <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No; <br /> THIS PERMIT EXPIRES l 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 :Wade in compliance with San Joaquin` <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> ,TOB ADDRESS/LOCATION CENSUS TRACT <br /> iL+ ✓ !I rte, ��l J 1. <br /> Owner's Name Phone _ <br /> Address City ' _i <br /> Contractor's Name a License # Phone ' <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN -/-7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR -/_7 PUMP REPLACEMENT /? <br /> Other r_7 q1 <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 /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 11 <br /> Cathodic Protection Rotary Type of Grout . <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type ;.of Pump H.P. <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP 'REPAIR: / / State Work Done. <br /> DESTRUCTION OF WELL: Well Diameter Ap roximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply wi.th �.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•best of- my.knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GRO ING AND A FIN INSPECTION, <br /> SIGNED - TITLELr/ <br /> (DRA PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED $Y r DATE42� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT -INSPECTION PHASE III N INSPECTIrm <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H '1426 Rev. 1-74 /7 -—2M <br />