Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> -To-r,--'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6181 <br /> 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 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , /-- =-C4' C-�!v CENSUS TRACT <br /> Owner's Name Phone r� <br /> f Address C acv City <br /> . Contractor's Name (f�N 14License # ,���' 2Phone�p�� .� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Qf/ ' PIT PRIVY < G <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE . PRIVATE DOMESTIC WELL":' PUBLIC DOMESTIC' WELL �-► `J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS,, <br /> IndustrialCable Tool Dia.' of Well Excavation <br /> ( Domestic/private Drilled Dia. of Well Casing _ <br /> Domestic/public Driven Gauge of Casing .fl. _ <br /> Irrigation X Gravel Pack Depth of Grout Se 1 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information 2-0 <br /> Geophysical Surface Seal Instalied By. <br /> r' <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 L Approximate Depth <br /> r Describe Material and Procedure <br /> I hereby agree to comply with 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 /> F information is true to the best of my knowledge .and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G NG D A4 AL INSPECTION. <br /> SIGNED TITLE ,Cv �. <br /> W PL T PU.AN 'ON RE LPSE SIDE) I` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �0 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ?? � 6 2M <br /> � E H 1426 Rev. 'lr-� <br /> 3/7 <br />