Laserfiche WebLink
SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOR.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <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 - /-7 <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ' <br /> JOB ADDRESS/LOCATION f + . CENSUS TRACT <br /> Owner's Name Phone <br /> r <br /> Address • 4 City <br /> a License #,,� L<`hone <br /> Contractor's Name <br /> r <br /> TYPE OF WORK (Check) : NEW-WELL /W-;DEEPEN /_/ 5 RECONDITION /_ DESTRUCTION /-7PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 F <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �0 PIT PRIVY <br /> SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE 'PIT 1Q� BOTHER <br /> k PROPERTY LINE ; PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL --' lie <br /> tttt INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial a 1e Tool Dia. of Well Excavation .� <br /> B6mestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection___� � r i .Rotary V Type of Grout <br /> Disposal Other . Other Information + <br /> Geophysical Surface SealfInstalled BY: <br /> k PUMP INSTALLATION: # ` <br /> Contractor <br /> Type of Pump H.P. t <br /> `PUMP REPLACEMENT: / / State Work Done <br /> PUMP `REPAIR.:"" - `` ` / State"Work Done _ <br /> R roximate <br /> � DESTRUCTION OF WELL: Well Diameter A PP Depth <br /> Describe Material and Procedure <br /> I <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 DAIS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distri't 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 bes of my knowledge and belief. I,WILL CALL FOR A GROUT INSPECTION. <br /> PRIOR TO GROU NG AND # FINAV)MSPEjCT ION. <br /> SIGNED TITLE r <br /> (D LOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ✓, <br /> ADDITIONAL COMMENTS: <br /> j PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION /� <br /> INSPECTION BY DATE INSPECTION BY DATE - /`� <br /> E H 1426 Rev. 1-74 <br />