Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE O CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> t Telephone : (209) 466-6781 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7- 37 yV° <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 Joaquin, <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 17() , I <br /> Owner's Name �---- <br /> CENSUS TRACT <br /> Phone <br /> Address <br /> 7l� City u. C <br /> Contractor's Name <br /> A License # <br /> —Phone <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN/�/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR 'Y/ PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> 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 n <br /> Domestic/private Drilled Dia. of Well Casing \ <br /> K Domestic/public Driven Gauge of Casing D <br /> Irrigation - Gravel Pack- Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposai Other Other Information <br /> Geophysical Surface Seal Installed By: }� <br /> PUMP INSTALLATION: # <br /> Contractor <br /> Type of Pump df <br /> H.P. rV <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /A/ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> 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 puttingthe..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 />?RIOR TO G T NG AND A FINAL IN E ION. <br /> SIGNED TITLE <br /> PL PIAN ON -VERSE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE -- <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION• <br /> INSPECTION BY DATE INSPkCTION BY <br /> ,i DATEz.S.•Z:� <br /> E H 1426 Rev. 1-74 - 1177 . _ 2M <br />