Laserfiche WebLink
SAN JOAQU-IN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 11J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X76 <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 /> JOB ADDRESS/LOCATION 0�2 <br /> CENSUS TRACT <br /> Owner's' Name Phone <br /> Address 3z City <br /> Contractor's Name License # Phone ' <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION f-1 DESTRUCTION <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 rr <br /> Industrial Cable Tool Dia. of Well ExcavationW <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 By: („ <br /> PUMP INSTALLATION: Contractor �l <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 / a <br /> Describe Material and Procedure �-d- <br /> I hereby agree to compl377wirfi 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T ROUT, AND 'FINAL IN PE CT ION. <br /> SIGNED ,� . TITLE <br /> DRAW PIs T PLAN 'ON REVERSE SIDE) 1. 7 7 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE d-Z 3 <br /> E H 1426 Rev. 1--74 376 2M <br />