Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOi FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. , ANNED <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S/ •-7 <br /> (Complete In Triplicate) <br /> Application is ereby made to the San Joaquin Local Health District for a permit to construct <br /> 3 <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 <br /> WcLLI CENSUS TRACT <br /> Owner's Name 41 <br /> Phone 3 <br /> Address 7'' " <br /> City <br /> Contractor Name <br /> License e d' Phone�fP -1,C =/ <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN -/-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / ] PUMP REPAIR /? PUMP REPLACEMENT %7 <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD. . CESSPOOL/SEEPAGE PIT OTHER \ <br /> r 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 -Si <br /> S <br /> Domestic/public Driven Gauge of Casing <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 B : <br /> PUMP INSTALLATION: Contractor LZ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> s <br /> PUMF :REPAIR: /? State Work Done <br /> ES-TRUCTION 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..weli in .use.. The above <br /> information is true to the best of- my knowledge and belief. I WILL qaV IJOR A GROUT INSPECTION <br /> 'PRIOR TO G OUTING AN A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE F INSPECTIQN <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> -E H 1426 Rev. 1-74 1--74 2M E` <br />