Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT ✓✓ <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,-1f-,21,;?- <br /> -,21,;?- <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 _ , ? = -t' .5o&�! ENSUS TRACT <br /> Owner's Name ` '^ �.� -'-' Phone _ C•' <br /> Address fVf !l City <br /> Contractor's Name ' nse _y_�7hon� <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN J / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 r <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ZGF'TSEWER LINES PIT PRIVY V <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 T <br /> L---D-Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal _ S•S <br /> Cathodic Protection _ __R117t"ary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B Q' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Q <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G D A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �! DATE = <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. - 1-74 <br />