Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-35� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -1-Z -7 <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 dek, ibed. This application is made in compliance with San Joaquin <br /> County Ordinance No. 18 �e_'Rule d Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI 5 CENSUS TRACT <br /> Owner's Name ` Phone <br /> Address City <br /> Contractor's Name 1 � ' <br /> License #�� _Phone fj� / <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN/7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION /d77PUMP REPAIR-/-7-pump REPLACEMENT /7 <br /> Other /7 — <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 0, <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 /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal installed B <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 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 gutting. 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 TO _GROUTjNG AND A FIN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID . � <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />,APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ji411FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -j 7 <br /> ...........� "o <br />+ E H 1426 Rev. 1--74 11/75 2M <br />