Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 T"CF- E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 .77�1305/ <br /> - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THISIPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> R .1 (Complete In Triplicate) <br /> Application is hereb made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereinidescribed. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and ,.he Rules and Regulations of the San Joaquin Local Health District. it <br /> JOB ADDRESS/LOCATION C3.S`' CENSUS TRACT' <br /> 1 <br /> Owner's Name , — <br /> Phone <br /> Address w City & <br /> a ' License �� �$�� Phone' f32-3/gl <br /> Contractar_As Name <br /> V <br /> TYPE OF WORK (Check) : NEW. WELL DEEPEN / / RECONDITION f_1 DESTRUCTION /7 <br /> PUMP INSTALLATION X PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES PIT PRIVY <br /> } SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> FPROPERTY LINE - PRIVATE DOMESTIC WELD PUBLIC DOMESTIC WELL �. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS v" <br /> Industrial f" Cable`Tool Dia, of Well Excavation F� C <br /> Domestic/private i Drilled'l Dia. of Well Cas* ' <br /> �1 <br /> a,Dames tic./pub.lic., . '. Driven Gauge of Casing in <br /> If {/ Gravel Pack �- 4Depth of Grout Seal. <br /> Cathodic Protection Rotary Y rType of Grout <br /> Disposal Other Other In€ormation3 <br /> Geophysical. Surface Seal Installed BY:------------- <br />' PUMP INSTALLATION: Contractor , ~� <br /> b Type of'-Pump H.P.- <br /> PUMP REPLACEMENT: / / State Work Done t <br /> rPUMP .REPAIR: / / State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> /L/ �Describe Material a 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 orregulatingwell'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, Iw3-11 '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 best of• my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IPRIOR TO GROUTI AN A FI L INSPECTION. <br /> SIGNED � '� t .� 7 TITLE, <br /> s x (DRAW PLOT PLAN ON REVERSE SIDE) <br /> 4HASEOR DEPARTMENT USE ONLY I DATE; <br /> [APPLICATION ACCEPTED BY <br /> "ADDITIONAL COMMENTS: PHASE I INAL ,�ISPECTIDN <br /> PHASE GROUT INSPECTION •, ATE <br /> INSPECTION BY DATE INSPECTION B <br />