Laserfiche WebLink
FOO OFFICSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E 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 <br /> (Complete In Triplicate) Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> and/or install the work herein described- ..This application is made in complianceermit �withnSan Jos ui <br /> County Ordinance No. 1862 and the Rules This <br /> of the San Joaquin Local Health Di q <br /> JOB ADDRESS/LOCATION strict. <br /> Ut _A 1 ,CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> Contractors Name <br /> License # Phone <br /> 0 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /? DESTRU <br /> I <br /> OtMP INST LATION /-7 �PUMP REPAIR PUMP REPLACEMENT /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES: PIT PRI . ; <br /> SEWAGE DISPOSAL'FIELD _ CESS OPOP OL/SEEPAGE P] <br /> PROPERTY LINE PRIVATE DOMESOTHER <br /> PUBLIC �MESTIC WELL <br /> INTENDED USE TYPE OF WELL TIC WELL-- - <br /> IndustrialCable Tool CONSTRUCTION SPECiFiCATIONS <br /> Domestic/private Dia. of Well Excavation <br /> Domestic Drilled Dia. of Well Casing <br /> /public <br /> Irrigation Driven Gauge of Casing <br /> Gravel Pack <br /> Depth of Grout Seal <br /> Cathodic Protection <br /> Disposal Rotary Type of (rout-- <br />.Geophysical' <br /> = '�—=---s Other Information <br /> } Surface Seal Installed B . St <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> _ H.P. <br /> PUMP REPLACEMENT: // State Work Done <br /> PUMP :REPAIR: <br /> jO State Work Done ✓ _ <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joa uin Local Health District <br /> and the State of California pertaining to or regulating well construction. <br /> q <br /> after completion of my work on a new well, I will Within FIFTEEN DAYS <br /> furnish the San Joaquin Local Health District <br /> TELL DRILLERS REPORT of the well and notify them before a <br /> Information is true to the best of. my knowled a and belieftting the..weli in use.. The above <br /> RIOR TO GROU NG AND A y g I WILL CAL A GROUT INSPECTION <br /> SIGNED INSPECTION. <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> RASE I FOR DEPn4ItTMENT USE ONLY <br /> PPLICATION ACCEPTED BY , <br /> DDITIONAL COMMENTS: {, DATE <br /> PHASE II GROUT INS CTION <br />,TSPECTION BY DATE pid FINAL INSPECTION <br /> INSPECTION BY DATEZ%zo-fib <br /> `E H 1426 Rev. 1-74 �- <br /> 1-74 2M <br />