Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF`F�_—or, OEFICE`USE: 1601 E. Hazelton Ave. , Stockton, Cal-i;f. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP 'PERMIT Permit No. 7k1_1a 5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued.' 7a <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 ��� - CENSUS TRACT <br /> Owner's Name Gj , Phone <br /> Address — City --- <br /> Contractor's Name , Licensed Phone <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPEN ITI RECONDITION / / DESTRUCTION <br /> PUMP�NSn1-LATT0n-/ /�.�,`PUMP REPAIR �/ PUMP REPLACEMENT /� <br /> Other / / -- G <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT'. OTHER <br /> PROPERTY LINE 'PRIVATE DOMESTIC WELL PUBLICDOMESTICWELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION,SPECIFICATIONS <br /> I Industrial Cable Tool Dia. of Well Excavatrion <br /> Domes`tid/priva'te Drilled Dia, of Well Casing;, <br /> `?,sDonnesti'c/ipubli c; . Driven Gauge of Casing <br /> irrigation w• w Gravel Pack Depth of Grout S'ea1', <br /> JCattiodc Protection Rotary Type of Grout <br /> r r ; <br /> Other viz. Other Information <br /> Geophysical `�'' t Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump . , H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: F State Work Done <br /> ti <br /> kDESTRUCTION 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 well'constructi.on. Within FIFTEEN DAYS <br /> after completion of my work on a new well, l will furnish the San Joaquin Local Health District <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 k GROUT INSPECTION <br /> PRIOR TO GROUT G AND A FI L KSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE I FIN INSPECTI N <br /> 16.ie- <br /> INSPECTION BY ]SATE INSPECTION BY AT ro <br /> 2M <br />