Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Ft�k OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Ad <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> �37VO_ <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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / 'ro ad - CENSUS TRACT <br /> Owner's Name LIT Phone <br /> Address f� <br /> �e�..<.t city <br /> Contractor's Name X4 �p -License Phone L2 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL j DEEPEN/ / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / 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 /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /1 <br /> Domestic/private drilled Dia. of Well Casing p <br /> Domestic/public Driven Gauge of Casing lfo <br /> Irrigation Gravel Pack Depth of Grout Seal s?/ <br /> Cathodic Protection J Rotary Type of Grout <br /> Disposal Other Other Information (� <br /> Geophysical Surface Seal Installed By: 2 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done 44 <br /> DESTRUCTION OF WELL Well Diameter y� Approximate Depth UN�Describe Material Material and Procedures <br /> I hereby agree to comply with all laws and regulations of the.-San JQaut '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 GRO ING AND A F AL IN PECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I ¢ —77 <br /> APPLICATION ACCEPTED BY DATE f 20 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE T,;01jFIN4ANSPECTI0,N <br /> INSPECTION BY DATE INSPECTION BY TE 171-7-7 <br /> E H 1426 Rev. 1-74 7.7/7 2 <br />