Laserfiche WebLink
/ SAN JOAQUI&LJ OCL HEALTH DISTRICT <br /> f0_R7OFFICE 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 Issued' <br /> (Complete In Triplicate) <br /> Application ie 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 AOCATIONCENSUS TRACT <br /> ,4j dA ILA <br /> Owner's Name Q Ci H � ,yl.� a� Phone ?j � 7 6 <br /> Address t <br /> City <br /> Contractor's,Name44 AdA <br /> _,. _ <br /> License �� � �� Phone <br /> TYPE OF WORK (Check): NEW WELL EEPEN , CONDITION %-7 DESTRUCTION f7 <br /> PUMPNSTALLATIO PUMP REPAIR/-7' 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' E PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Zd If w\,k) <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal U <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> GeophysicalSurface Sealxlnstalled 'By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done ` <br /> PUMP ,REPAIR: / /c,,,-State Work Done <br /> DESTRUCTION OF WELL: Well, Diameteic . "' <br /> Approximate Depth <br /> Describe Materiarckid;:Pro cedure,. <br /> I hereby agree to comply with all ,.laws and.-r-egdlation;s of--the San J6aquin,Local Health District <br /> and the State of California pertaining'' : or regulatixig s "'ellonstructiono .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•b'est of my; knowledge an�beliet, I WILL CALL FOR A GRQUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED _ Q1 TITLE ° <br /> —�" (DRAW PLOT PLAN ON REVERSE$SIDE <br /> PHASE I Z <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY1 <br /> DATE 5WE 24 i <br /> ADDITIONAL COMMENTS: , <br /> PHASE II GROUT INSPECTION PHA I $tAL YNSPECTI.O <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> {4 { <br /> E H 1426 Rev. 1-741./ om <br />