Laserfiche WebLink
{ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k FOF OFFICE USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone: -(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r <br /> THIS -PERMIT- EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ;2- -2- 7 <br /> - (Complete In Triplicate). <br /> Application is hereby made to the San Joaquin Local Health Distract 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 ,�' �� CENSUS TRACT ' <br /> Owner's Name (� _ Phone <br />[ Address 71 l? a�Llf =� City <br /> Contractor's Name License hone0 1 -- <br /> r <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / J RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION- 1 PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC .TANKp SEWER LINES PIT PRIVY _ <br /> SEWAGE �DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIMATE 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 Dia, of Well Casing < <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation"° Ga'v`e'ZPack""' '^"'""Deph of�Grout�Se`al <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal # Other Other Information <br /> Geophysical Surface Seal Installed By-0, f�G <br /> PUMP INSTALLATION: Contractor ( <br /> Type o'-Pump H.P. <br /> PUMP REPLACEMENT:' / / State Work Done <br /> PUMP .REPAIR: <br /> / / ,State Work Done= <br /> DESTRUCTION OF WELL: Well Diameter Fj <br /> �•� , Ap roxi e�epth <br /> Des ibe M teri a do educe <br /> I hereby agree to comply ;;`i 71-1 ws and gulations o the San Joaquin Local Health District <br /> and the State of California pertaining to orregulating 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 thewell in use. The above 1 <br /> information is true to -the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING D A FINAL INSPECTION. <br /> SIGNED i ! TITLE <br /> .0010- <br /> (DRAW PLOT PLAN ON REVERSE SIDE)- <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: { <br /> GROUT INSPECTION P 5 FINAL•INSPECTION J <br /> INSPECTION BY DATE INSPECTION BY DATE �a-�1��g <br /> E H 1426Rev. - I-74 0/77 _ 2M <br />