Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE- � ` <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION, OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued f/ 77 <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 /> I <br /> JOB ADDRESS/LOCATION 14/ l �D <br /> CENSUS TRACT _ <br />� Owner's Name kj -� <br /> ���� Phone a7/lJ <br /> Address <br /> City <br /> Contractor's Name 7 <br /> is p <br /> License Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN <br /> / / RECONDITION /_/ DESTRUCTION /? <br /> PUMP INSTALLATION %/ PUMP REPAIR / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK < <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL . :x. <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable-.Tool Dia. of Well Exca <br /> Domestic/private Drilled', vation <br /> -Dia. of.kWel7:;�Casing 1� <br /> Domes tic/pulilic Driven. _. _ <br /> IrrigationGauge "of..-Casing <br /> '--.G.ravel Pack Depth of Grout Seal <br /> Cathodic Protection �Rotarq! Type of Grout <br /> Disposal Other. <br /> _4_ <br /> Other Information <br /> - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT; State Work Done <br /> PUMP REPAIR: � State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> } r <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District I <br /> and the State of California pertaining to or regulating well "construction. --Within FIFTEEN DAYS <br /> sfter completion of my work. on a new well, I will furnish the San Joaquxn,,Loeal Health District a <br /> BELL DRILLERS REPORT of the well, and notify them before putting the- well in use.'. The 'above <br /> information is ue to the best o my knowledge and belief. I WILL CALL FOR A G OUT INSPECTION <br />'RIOR TO GRO NG D A FINAL IN ECT U001 <br />;IGNED <br /> TITLE ' <br /> PLOT PLAN ON REVERSE SIDE) <br />'RASE I FOR DEPARTMENT USE ONLY <br /> TPLICATION ACCEPTED BY <br />,DDITIONAL COMMENTS: DATE <br /> NSPECTION BY <br /> PHASE II CTION r I/FIN INSPECTI N } <br /> DATE INSPECTION7 <br /> ATE <br /> E IZ�426 Rev. • 1-74 .. ,-.-fe <br />