Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOLiOFFI T USE: 1601 E. Hazelton Ave. <br /> 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 <br /> (Complete In. Triplicate) Date Issued <br /> Application is hereby de to the San Joaquin Local Health District fora permit <br /> and/or install the work herein described. P t to construct <br /> . County Ordinance is <br /> No. 1662 and the Rules andTRegulationstofnthe SaneJoaquinpLocaleHealt San Joaqui <br /> JOB ADDRESS/LOCATION Health District. <br /> CENSUS TRACT <br /> Owner's Name f <br /> Phone ,-- <br /> Address ' <br /> hone 'Address ' <br /> City <br /> Contractor's Name <br /> 1904 <br /> LicensePhone <br /> TYPE OF WORK (Check) : INEW WELL DEEP Ek '/_' RECONDITION /-7 DESTR <br /> UMP INSTALLATION /� FUME REPAIR ' UCTION f <br /> ,Other /% ' /� PUMP REPLACEMENT /? <br /> DISTANCE TO <br /> NEAREST: SEPTIC TANK EWER LINES <br /> X SEWAGE DISPOSAL FIELD PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE <br /> /.d_PR1vATE OTHER <br /> DOMESTIC WELL P <br /> INTENDED USE TYPE OF WELL UBLIC DOMESTIC WELL�� <br /> IndustrialONSTRUCTION SPECIFICATIONS - <br /> Domestic -_� Cablej'Tool Dia. of We11 Excavation 4 <br /> —� <br /> Domestic/private Drilled (" <br /> _ Domestic Dia. of Well Casing <br /> Irrigation _ � Driven Gauge of Casing <br /> �_ Gravel 'Pack - 'Depth of Grout Seal . . <br /> Cathodic Pr_otect_ion v Rotary T — <br /> Disposal Other - <br /> . Geophysical <br /> of Grout <br /> Geophysical - -.-.�� Other Information 42 <br /> . Surface Seal Installed B ; <br /> PUMP INSTALLATION*41 ' <br /> Contractor <br /> TYPe1 of Pump <br /> H.P.. <br /> PUMP REPLACEMENT: . � <br /> �/ State Work Done '< <br /> PUMP- REPAIR- <br />.. . . =- D <br /> _- �/-.�_�S.ta-te-'Work _ <br /> one <br /> DESTRUCTION OF WELL: -ell Diameter <br /> Describe Material and Procedure APProximate Depth <br /> I hereby agree to compi4with all .laws and regulations of the San Joaquin Local Health <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> District <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 &e .well and notify them before putting. the .well. in.use.... The above <br /> information is true to ttie best-of my knowledge and belief. I WILL CALL FORA GROUT INSPECTIO <br /> PRIOR TO G OUTING AN A "NAL PECT ON.. N <br /> SIGNED <br /> D L ~ PLAN ON TITLE <br /> RISE SIDE <br /> PHASE I <br /> • �, �. N FOR DEPARTMENT- SE ONLY,4�. <br />.gTLICATION ACCEPTED BY <br /> kDDZTIONAL COMMENTS: A DATE ' 7'L7 S "� <br /> IILPROUT INSPECTION <br /> INSPECTION BY i n[ DATEP S I INAL INSPECTION <br /> Jr� INSPECT ON BY DATE <br /> E H 1426 Rev.- 1--74 <br />