Laserfiche WebLink
_ yv � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Ordin }ce No. 1862 .and the Rules a Regula ions of hen Joaqu' Lo al Health District. <br /> JOB ADDRESS/LOCATION CSUS- TRACT <br /> Owner's Name Phone r <br /> 17S <br /> Address f - <br /> City <br /> 0 <br /> Contractor's Name �� r. - License i��� Phone gad <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /-7 _ J <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / �J <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 M. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 a Depth of Grout Seal <br /> Cathodic Protection Rotary -Type of Grout <br /> Disposal Other "` Other Information <br /> Geophysical -'b Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor � 7 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> T <br /> PUMP REPAIR: / / State Work Done I <br /> i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure , •. <br /> i <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'-' ;l <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 GROUTINGA INAI IN �EION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY / 7, 1 <br /> PHASE z <br /> APPLICATION ACCEPTED BY ✓� DATE L <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. . 3--74 n�71 2M <br />