Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO-R*OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued -a <br /> (Complete In Triplicate) f �= <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 <br /> CENSUS TRACT <br /> 3 <br /> Owner's Name Phone <br /> Address , Cityj/ <br /> Contractor's Name y License # Phone <br /> 3y <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN/7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALI;ATION / / PUMP'REPAIR�/L__7 pW` pLACEMENT %7 � <br /> Other.-/7/-- _. <br /> DISTANCE TO NEAREST: -SEPTIC TANK SEWER LINES - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD --"-CESSPOOL/SEEPAGE PIT OTHER Ij <br /> .j <br /> r., <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ;3 <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 Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> eal s� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed BZ: <br /> `j <br /> i C�F7 R LDS !$ Wpr �~ p�aM. wi �PUMP INSTALLATCON: . Contractor DPILLZP <br /> 4V 7tf4 IACATIOIJ w <br /> 4 Type of Pump " H.P. <br /> Tr 14.d <br /> I' PUMP REPLACEMENT. <br /> / / State Work Done i <br /> PUMP ,REPAIR: State Work Done - <br /> ES•TRUCTION OF WELL: g <br /> 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-oryregulat.ing well construction:"- WithinFIFTEEN 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T GRO A F.UAL INdPECTION, . <br /> SIGNED �fy�— TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE ' <br /> \1, <br /> DEPART NT USE ONLY <br /> 4'PHASE I APPLICATION ACCEP V14L1 n1gT DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PI•IAS F AL NSPECTIO <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> • , <br /> ,w f <br /> Rev. 1-7 <br />