Laserfiche WebLink
SAN JOAQU.IN LOCAL HEALTH DISTRICT <br /> FOR 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 U771 <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 3 r k- G r CENSUS TRACT --- <br /> Owner's Name ` [ Q �? Phone _ <br /> Address to 69 City <br /> Contractor's Name tI License # �'"I'hone _'7G <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR /,<- PUMP REPLACEMENT <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 STYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation VJ <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 _ <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 well in use. The above <br /> information is true to the best of my knowledp]e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT NG AND FINAL IN IU <br /> SIGNED 000 A TITLE <br /> fDT9W-PL0T PLAN ON VERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPtCTION PHASE III/FINAL INSVECTION <br /> INSPECTION BY DATE INSPECTION BY ,� � DATE <br /> 2M <br /> E H 1426 Rev. - 1-74 <br /> n�77 _ <br />