Laserfiche WebLink
° <br /> SAN JOAQUIN: LOCAL HEALTH DISTRICT <br /> FO$rOFFICE USE: 1601 E. Hazeltbn, Av'e °;'`Stockton, Calif, 4SCANNED <br /> Telephone:' (209)" 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -/per�J <br /> THIS PERMIT EXPIRES, 1 YEAR..•FROM DATE ISSUED Date Issued <br /> (Complete In ,1riplicate) <br /> Application is hereby made to the San Joaqufn ,Lgcal FIealth 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 sthe Rule and gul igx�s e San Joa�in Local ea]�t Di trict, <br /> !� _ <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name <br /> Phone O <br /> Address City 10�2 <br /> Contractor's Name License #/j / Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/-7- 'RECONDITION /-7 DESTRUCTION f7 <br /> ., � PUMP INSTALLATION; UMP REPAIR /-7-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 <br /> Industkial � � Cable Tool _» Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing all <br /> _ Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ff <br /> Cathodic Protection Rotary Type of Grout .. <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B ; <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: f /_-/ State Work `Done W <br /> y• <br /> D S-TRUCTION_OF WELL: Well Diameter - Approximate Depth <br /> Describe Material and ,Procedure <br /> I hereby agree to comply with all lawsfand-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 ICOR A GROUT INSPECTION <br /> PRIOR TO OYDUTING AND A FINAL INSPECTION. <br /> SIGNED 7 TITLE <br /> (DRAW, PLOT-PLAN-ON REVERSE SIDE _.. <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY C ' DATE z-/,F <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE 'J <br /> E H 1426 Rev. 1-74 1-74 2M <br />