Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> { Telephone : (209) 466 -6781 <br /> #4 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 7/,5o.�L— <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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Ad d r e ss b ox ��6�lfZ� <br /> i City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /—/ DESTRUCTION <br /> AL . <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP RFPLACEMEN-X/— <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 ^� q <br /> Domestic/private Drikled--- • - _ Dia. of Well Casing 1� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of 4G-roiut <br /> Disposal Other Other Information <br /> Geophysical Surface. Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> IS- <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Pro educe <br /> I hereby agree to comply wi h all laws and regulaltions of the San. Joaquin Local Health District <br /> and the State of California pertaining to or'regulati.ng 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 b•e1i7&F-. I GdTLL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPWTION. <br /> 'SIGNED X TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: r <br /> PHASE II GROUT INSPECTIONS - PHA E I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - X101 <br /> E H 1426 Rev. . 1-74 /77 2M <br />