Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO& 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 Date Issi-ld <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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - i CENSUS TRACT <br /> Owner's Name / <br /> t Phone ➢V <br /> Address City <br /> Contractor's Name ,� - License ✓ ho <br /> TYPE OF WORK (Check) : NEW WELL, f�/ DEEPEN / RECONDITION / DESTRUCTION /3 _ <br /> PUMP INSTALLATION PUMP REPAIR f� / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK iF r SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITOTHER <br /> r_ PROPERTY LINE - PRIVATE DOMESTIC WELL: ______PUBLIC DOMESTIC F7ELI. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool_ I)ia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of. Casing <br /> ---�, <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection y Rotary Type of Grout <br /> Disposal _ Other Other Information. <br /> Geophysical. Surface Seal- :Installed By: <br /> -- - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> c� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED L. ;- ', � TITLE _ <br /> i- (DRAW PLOT PLAN bN REVERSE SIDE) <br /> FOR DEPARTMENT USE� ONLY <br /> PHASE T ' <br /> APPLICATION ACCEPTED BY _--��; /, � DATE <br /> ADDITIONAL COMMENTS: _ �-+- <br /> PHAS II GROUT INS' CTION PHASE, III/FI AL INSPECTION <br /> INSPECTION BY DATE _� . - INSPECTION BY DATE <br /> E H 1426 Rev- 1-74 01177 _ 2M <br />