Laserfiche WebLink
SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOfi OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3391 <br /> APPLICATION <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> J (Complete In Triplicate) <br /> Application is Aereby 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 Ordinance No. 18 2 and the R s_ and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name r ' Phone <br /> Address y� � City <br /> Contractor's Name -� d �' ', .License � - Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION & PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <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 <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 d <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> - Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: (� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done /lLG e� <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate 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 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 GMTAND A ,FINAL T ECTIO <br /> SIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEO�647 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION. PHAS I I/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY Aj DATE <br /> E H 1426 Rev. 1-74 <br /> 77 2M <br />