Laserfiche WebLink
G SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR-OFFICE USE: ' 1601 E. Hazelton Ave., ;Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pate Issued <br /> ' (Complete In Triplicate) <br /> Application is Aereby 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 /> Count dinance No. 1862 and the Rules,,and Regulations of the San Joaquin Local Health Dist#ct.JOB SS/LOCATION g - - CENSUS TRACT <br /> Owner's Name I Phone -�41Q '� <br /> Address ti City <br /> Contractor's Name nn lftno i• License # Phone ,J - <br /> TYPE OF WORK (Check): NEW WELL All DEEPEN RECONDITION I DESTRUCTION %T <br /> PUMP INSTALLATION /-7 PUMP REPAIR /_/ PUMP REPLACEMENT /7 <br /> Other <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 -T Q <br /> Industrial Cable Tool Dia. of Well Excavation ` <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection V�- Rotary Type of Grout Apgi <br /> Disposal Other Other Information G- -- <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work <br /> PUMP :REP/ R; �_ State Work Done <br /> oL,p 6v 4-o h Pg e eelD o N H- <br /> D STRUCTION OF WEL*- Well Diameter / A roximate Depth _ <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health istrict <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 GRPUTING AND INAL IN ECTI N. <br /> SIGNED TITLE ------- <br /> D PLOT LAN ON REV E SIDE <br /> FOR DEPARTMENT USE ONLY IF U <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 �-�� <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GRO INSPECTION PHASE II FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE <br /> E H - 1/17 ' 2M /~ <br />� 1426 Rev. 1,74 <br />