Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFr.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�W <br /> THIS PERMIT EXPIRES 1YEAR FROM DATE ISSUED, Date Issued', <br /> (Complete In Triplicate) <br /> 7 <br /> Application is hereby made to the San Joaquin Local 11calth District for a permit to construct <br /> and/or install the work herein described. This appXication is made in compliance with San Joaquin' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District.. I <br /> JOB ADDRESS/LOCATION �. . <br /> CENSUS TRACT <br /> Owner's Name <br /> ' Phone <br /> f Address ® C:�, t , „ -4 <br /> City , �. <br /> Contractor's Name _ <br /> License _ Phone - a <br /> r <br /> TYPE OF WORK (Check): NEW WELL �,��-�^^ DEEPEN/ /'? DESTRUCTION <br /> PUMP INStJ1LA,TION / PUMP REPAIR ON /_7 <br /> . � I� PUMP REPLACEMENT %T <br /> Other E7 . . . . . <br />'DISTANCE TO NEAREST: SEPTIC TANK O SEWER LINES • PIT PRIVY <br /> SEWAGE DISPOS4. FIELD CESSPOOL/SEEPAGE PIT OTHER �^ <br /> PROPERTY LINE/V"PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ; <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled <br /> Domestic/public Driven Dia. of Well Casing <br /> Gauge of Casing : p <br /> Irrigation Gravel Pack - Depth of Grout Seal <br /> Cathodic Protection Rotary `� <br /> Disposal _. -� OtherType of Grout <br /> .�� _ Other Information <br /> -- Geophysical Surface Seal Installed 'BX:' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ . r �"' sAP. / <br /> or <br /> PUMP REPLACEMENT: , / / State Work Done ° ^� r <br /> PUMP 'REPAIR: / 7 State Work Done <br /> DESTRUCTION 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-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 well and notify them before putting.the-well.�n.use.. The above <br /> information is true to e•bes�C-of-�my knowledge and belief. I WILL CALL 'FOR 'A, GROUT INSPECTION <br /> PRIOR TO GROUT GIN �I SP IONS <br /> SIGNED t 9'p TITLE { <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> _ <br /> APPMLICATION ACCEPTED BY = <br /> ADDITIONAL COMMENTS: <br /> P I G OUT INSPECTIO P, AL INSPECTI <br /> INSPECTION BY DATE INSPECTION ,' DATE <br /> f <br /> E H `1426 Rev. } <br />