Laserfiche WebLink
FOSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> HiOFFICE SE: 1641 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> -3c <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaqui: <br /> County Ordinance No. 1862 and the Rules and egulations of the San Joaquin Local Health District. <br /> JOE ADDRESS/LOCATION <br /> ` r�: � �eSq,) CENSUS TRACT <br /> Owner's Name ler <br /> z- Phone <br /> Address <br /> City J�[,� ��. <br /> Contractor's Name <br /> License # ZfJ2W__Fhone .. <br /> i <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN ,/? RECONDITION /_7 DESTRUCTION <br /> j 3 PUMP INSTALLATION PUMP REPAIR <br /> i Other /% 1-7—Pump REPLACEMENT /? <br /> DISTANCE TO NEAREST: SEPTIC TANK _ <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD _ CESSPOOL/.SEEPAGE PIT _ OTHER <br /> PROPERTY LINE w PRIVATE DQNESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE �pE OF WELL w <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> -Domestic/private Cable Tool Dia. of Well Excavation <br /> - Domestic/public well <br /> Dia. .of Well Casing <br />'. Irrigations.:-Driven, Gauge of Casing <br /> g, . Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal <br /> GeophysicalOther Other Information <br /> -------• <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor `� J <br /> Type of Pump • <br /> PUMP REPLACEMENT; / / State Work Done y <br /> PUMP !REPAIR: /? State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comp}y 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 DRILERS REPORT of the well and notify them before putting. the..well in use. <br /> information is true to the—best—of my.knowled a and elief The above <br /> PRIOR TO G I G AND A FINAL INSP $ I WILL CALL FORA '-ROUT INSPECTION <br /> SIGNED _ <br /> TLEp <br /> D P OT. ON RSE SIDS <br /> PHASE I <br /> R EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BYDATE PHASE III FINAL INSPECTIO <br /> INSPECTION B DATE <br /> E H 1426 Rev. 1-74 <br />