Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOPirOFFICE 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 EVIRES I,YEAR FROM DATE ISSUED Date Issued bb <br /> S ' (Complete In Triplicate) <br /> Application is heteby made to the San Joaquin Local Health District for a permit to construct <br /> acid/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 /> . OB ADDRESS/LOCATION (p g L VAI CENSUSr TRACT <br /> Owner r s Name Phone g�a <br /> Address` y., ) <br /> City ?�1 <br /> Contractor"s Name'! . Alj.Z/ <br /> License #if OIQ Phone ,,;Qv <br /> TYPE OF WORK -(.Check}: NEW WELL /-7 DEEl 7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP: INSTALLATION / / PUMP REPAIR /? PUMP REPLACEMENT . ,g . <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER,•.LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD may,' CBS SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC <br /> WELL PUBLIC DOMESTIC WELL <br /> � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Taal a' Dia. of Well Excavation 0 <br /> Domestic/private <br /> Drilled— ,;, �Dia.~'of Well Casing <br /> Domestic/public; Driven Gauge of Casing a <br /> Irrigationn ' <br /> Gravel Pack' Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION,:—Coli'trac dor <br /> Type of Pump H.P. - <br />` PUMP REPLACEMENT.:; State,Work Done .� <br /> PUMP=:REPAIR: /_ State -work''Done <br /> E&TRUCTION OFTWELLa <br /> Well Diameter <br /> Approximate <br /> mats <br /> PP 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..wel1 in-use. The above <br /> information is true to the best of- my knowledge and belief:- I WILLCALL F R A GROUT INSPECTION <br /> PRIOR TO GROUTMG ANDA NAL INSPECTION, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> - � FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY b� e DATE . <br /> ADDITIONAL COMMENTS: <br /> V PHASE II GROUT' INSPECTION ;' PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1Y� <br /> t �E H 1426 Rev. 1-74 1-74 2M <br />