Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 19 <br /> '1`1 - 5$ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate). <br /> 4P <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 NameI r Phonev <br /> Address Sod <br /> 4-Yr City . <br /> Contractor's Name License #lj,'U Phone �j <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/Pr DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <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 /> j/ Industrial -� Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> ✓Domestic/public Driven Gauge of Casing <br /> Irrigation Irri <br /> g Grav1el Pack .Depth of Grout 5ea1 <br /> Cathodic Protection Rotary Type 6f-Gr-out Z r <br /> Disposal Other Other Informatibn� _ - <br /> Geophysical Surface Seal Installed By-:.- .- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 0 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR: / / State Work Done <br /> PES-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 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-belief--IWILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND, A FINAL INSPECTION. LL <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r DATE 2-9)) <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - O -78 <br /> E H 1426 Rev. 1-74 1177 2M <br />