Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FW*OFFICE USE: ® 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 ulations,of the SAn Jo ui Local Health District. <br /> JOB ADDRESS/LOCATION 61-7� CENSUS TRACT <br /> Owner's Name Phone <br /> Address 42 City _ <br /> Contractor's Name License -�jj1 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION /P'-PUMP REPAIR-1-7—PUMP REPLACEMENT f7 <br /> Other /_7 <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 O <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 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 4 <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 <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 putting.the..wel1 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 TO GROU ANDA IN INSPECTION. <br /> SIGNED TITL <br /> DRAW PLOT PLAN ON REVERSE S E <br /> PHASE I FOR DEPARTNMT .SE ONLY <br /> APPLICATION CATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PEW 'Tiulm INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY DATE -J� <br /> E H 1426 Rev. 1-74 2M <br />