Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 76-7�o p <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/LOCAT ON CENSUS TRACT <br /> Phone <br /> Owner's Name <br /> Address opCity <br /> I R <br /> Contractor's Name ense <br /> TYPE OF WORK (Check) : NEW WELL DEEPE RECONDITION / / DESTRUCTION /^T <br /> PUMP INS ALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP FIELDS /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 \4) <br /> Domestic/private Drilled Dia. of Well Casing �u <br /> Domestic/public Driven Gauge of Casing W <br /> Irrigation Gravel Pack Depth of Grout Seal m <br /> Cathodic Protection Rotary Type of Grout l� <br /> Disposal Other Other Information <br /> Geophysical Surfac "eal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> �Q <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' onstruction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> information is, true to the bes my. knowledge and belief. I WILL FOR A GROUT INSPECTIOT <br /> PRIOR TO GRO N AND FINAL PECT <br /> SIGNED <br /> TITLE �1`r <br /> �I�DW �L �PL�� ON RE RSE SIDE) <br /> FOR EPARTMENT USE ONLY / <br /> PHASE IDATE `- b <br /> APPLICATION ACCEPTED BY <br /> -- Ej�z - <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECT N PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ��, /� DATE /e4 <br /> 3�. <br /> E H 1426 Rev. 1-74 <br />