Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �.OVFICE USE: 1601 E. Hazelton Ave,. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 7,ICATION 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 he Rule and Re ul tions o the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �j„P,t �� `� �J,(�J CENSUS TRACT <br /> Owner's Name Cj ky�---t 1j-,,k t)l D a_;; tc Phone <br /> Address .� ( .� l,f*i:ti kA 1(r City , <br /> Contractor's Name O ,� License # Phone T Y-r&, <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION 17 <br /> PUMP INSTALLATION jg/ PUMP REPAIR / / PUMP REPLACEMENT 17 <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 <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 /> �X 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 j r�,;,i� H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /-7 State Work Done <br /> 2EES,TRUCTION 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED a�,ice ,d TITLE r <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS ' II GROUT INSPECTION PHASjAill INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> ,i E H 1426 Rev. 1-74 1-74 2M <br />