Laserfiche WebLink
Pal) SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _097OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _Z�-� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued Y J7-7� <br /> `°17'ISle (Complete In Triplicate) <br /> Appl cation is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or instar 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 CENSUS TRACT <br /> Owner's Name -eesx, . Phone <br /> Address City ' <br /> Contractor's Name License Phon <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN '/-7 RECONDITION %f DESTRUCTION I <br /> PUMP INSTALLATION REPAIR -/_7 Pi)MP REPLACEMENT 17 <br /> Other A�/f <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 - -- <br /> Irrigation Gravel Pack Depth of Grout Seal G <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 /> � f <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: /t_-['State Work Done <br /> DES•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..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 GROyMG AND A FINAL INSPECTION. <br /> SIGNED _ , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)' <br /> FOR DEP&RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASZ III AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE l� <br /> E H 1426 Rev. 1-74 h/75 2m <br />