Laserfiche WebLink
r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rFOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ _ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.S-41,11t J <br /> 7S=S1.- 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 Ordinanceo. 862 d the Rules and Regulations of the San Joaquin Local Health District. <br /> v/ 3 <br /> JOB ADDRESS/LOCATION," <br /> !2 "-gGtrCENSUS TRACT <br /> Owner's Name Phone <br /> Address - D , <br /> City <br /> Contractor's Name icense c %'Ate jton L� <br /> TYPE OF WORK (Check): NEW WELL PrDEEPEN -/7 RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION G- REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWS LINES PIT PRIVY f <br /> SEWAGE DISPOSAL FIELD <br /> VATE CE OOL/SEEPAGE PIT OTHER <br /> —_ PROPERTY LINE -_PRI DOMESTIC WELL UB <br /> PLIC STIC WELL <br /> INTENDED USE TYPE OF L CONSTRUCTION SPECIFICATIONS <br /> I atrial able Tool Dia. of Well Excavation <br /> omeatic/private Drilled Dia. of Well Casing (3 <br /> Domestic/public Driven Gauge of Casing <br /> �rigation Gravel Pack Depth of Grout Seal _ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PM .REPAIR: /_7 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.knowledge and belief. I WILL WL FOR A GROUT INSPECTION <br /> PRIOR TO GROU NG ANDA FINAle INS E®£ION. <br /> SIGNED TITLE <br /> D LOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE /O f ��-- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE HINDU INSPECTION <br /> INSPECTION BY DATE io INSPECTION BY DATE -.:/ -2� <br /> E H 1426 Rev. 1-74 <br />