Laserfiche WebLink
' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE: 1� 1601 E. Hazelton Ave. , Stockton, Calif.ob <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 <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 �JRules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Gl!� e� CENSUS TRACT <br /> Y (/ <br /> Owner's Name Phone <br /> Address City .� <br /> Contractor's Name � c�c License iVL2l2 Phone_? r � <br /> TYPE OF WORK (Check) :_ NEW WELL DEEPEHV -fRECOND�TION /—T DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAR / / PUMP REPLACEMENT J57 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK R LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED-USE _ .1 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. *of Well Excavation <br /> Domestic/private Drilled Dia. iof Well Casing <br /> Domestic/public Driven Gauge of C4sing <br /> Irrigation Gravel Pack Depth of Giout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal-- "�' - Other _ -Othet Infozmation <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . ,P State Work Donee <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure s <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 a <br /> WELL DRILLERS REPORT of the well-' and notify them before puttiqg theYwell in use. The above <br /> information is u to the bes of my.knowledge and belief. WILL ALL FOR A GROUT INSPECTION. <br /> PRIOR TO GROUTI#0 ANWA FI NSPECTIO <br /> SIGNED - TITLE <br /> D W. PLAN 'ON RSE SIDE •-�-- * r�'1. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY -, ',�� =' �3/ n DATE <br /> ADDITIONAL COM MEr1TS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION•BY DATE <br /> E H 1426 Rev. 1-74 <br />