Laserfiche WebLink
.As �AN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 -7-7-/5-(- C <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -ZZ- <br /> THIS <br /> o. -ZZ—THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedD�� <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 J qu;hn Loca He0l,th District. <br /> JOB ADDRESS/LOCATION A7 ""` p� rCENSUS TRACT <br /> fr` `f Phone <br /> Owner's Name/ <br /> Address �/ � }` City <br /> Contractor's Name °r License # Phone ���� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION /� <br /> PUMP INSTLATION/' /' ..PUMP REPAIR / / PUMP REPLACEMENT - /_T <br /> AL <br /> �.O the . ./=/. - Y <br /> DISTANCE TO NEAREST: SEPTIC'TANK: I 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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing v <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 C; Surface-Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> / <br /> PUMP REPLACEMENT: / / State Work Done <br /> T s' <br /> PUMP .REPAIR: „/ / State-Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f Describe Material and Procedure <br /> h 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 putting thewell in use. The above <br /> information is true to the best of my. knowledge and belief. I WILL CQ FOR A GROUT INSPECTION <br /> PRIOR TO UTING AND NAL INSP CTION. <br /> SIGNED TITL �. <br /> DRAW P T' PLAN 'ON RE FRSE SI E) <br /> F EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION AtCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA IN INSPECTI <br /> OA <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 ? -- <br />