Laserfiche WebLink
{ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �OF.OFFIGE USE: ' 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br />` L/ <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Date Issued,2 <br /> (Complete In Triplicate) <br /> Application is Aereby 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 DistO ct. <br /> JOB ADDRESS/LOCATION a Q 3 <br /> CENSUS TRACT <br /> Owner's Name <br /> r Phone a <br /> Address <br /> Lel <br /> City ' <br /> �, <br /> Contractor's Name � - ' <br /> License Phone <br /> TYPE OF WORK (Check) : NEW WELL <br /> / / DEEPEN /_/ RECONDITION 1-7DESTRUCTION /_7AL <br /> PUMP INSTLATION / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other O- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER W <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <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 r Gravel-'Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout � ! <br /> Disposal Other .. Other Information <br /> Geophysical , I <br /> Surface Seal Installed B <br /> PUMPINSTALLATION• Contractor ' 1 I <br /> . <br /> -`TYpe of Pump ._ <br /> 0 _ <br /> _ _ H.P. <br /> PUMP wREPLACEMENT / / State Work Done <br /> - �- <br /> a <br /> PUMP :REPAIR: <br /> State Work Done <br /> 40 <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health DistricC <br /> and the State of California pertaining to or regulating well "construction. Within <br /> after completion of my work on a new well, I will furnish the San Joaquin Local HealthTEEN Distri.ct a <br /> WELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above <br /> information is true to thA best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AND A AL INSPECTIO <br /> SIGNED TITLE <br /> ( RAW PLOT PLAN ON REVERSE SIDE) <br />?RASE I �f <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br />'NSPECTION BY DATE INSPECTION BY DATE <br /> E H 149A <br />