Laserfiche WebLink
= = SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: ! 1601 E. Hazelton Ave. , Stockton,`Calif. ' <br /> Telephone : (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedj--� <br /> ' '37 <br /> Complete In- Triplicate) <br /> c <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 Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. a <br /> g � <br /> JOB ADDRESS/LOCATION / CENSUS TRACT j <br /> Owner's Name Phone 1rfI 1 <br /> Address �'; City <br /> i <br /> Contractor's Name License # _&e�Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /7 RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY V`1 <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 t s Driven- Gauge-of=Casing^— <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> GeophysicalSurface Seal Installed By : �. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> - <br /> PUMP REPLACEMENT: / / State Work Done•� � �c�/ <br /> PUMP -.REPAIR: _ <br /> / / State Work Done <br />}ES•TRUCTION 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 Local Health District <br /> and the- State -'of California pertaining to or regulating we11 'construction. Within FIFTEEN DAYS,-5 <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> BELL DRILLERS REPORT of the well and notify them before putting the well. in use.. The above <br /> Lnformation is .true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> k. <br />'RIOR TO GRO G 9D A FINAL INSPE ION. <br /> SIGNED TITLE <br /> (DRAW PLOT. PLAN ON REVERSE SIDE) j <br /> FA DEPARTMENT USE ONLY <br />?RASE I <br /> OPLICATION ACCEPTED BY / DATE / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II/FIN-4 INSPECTION <br /> INSPECTION BY / �` DATE INSPECTION BY ,d' ( DATE <br /> ^1E H 1426 Rev. 1-74 1177 _ 2M <br />