Laserfiche WebLink
�0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&."OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2�/�lrJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> -- - (Complete InTriplicate) <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 Or4inance No. 1862 an the Rules and Regulatio a of the San Joaquin Local Health District. <br /> I OB ADDRESS/LOLCATO�-�-�r F r CENSUS TRACT U 13 --O-K-43 <br /> Owner's Name f Phone <br /> Address City, <br /> s <br /> Contractor' Name ,.License„ _ hone <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN/7 RECONDITION 17 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY p <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER a <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialTool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /n <br /> �rigation Gravel Pack Depth of Grout Seal <br /> Cathodic Pxotect_ion Rotary Type of Grout L`. <br /> Disposal Other Other Information ^ <br /> Geophysical Sumface Seal Installed B : <br /> PUMP INSTALLATION* Contractor l�?� <br /> Type of Pump V H.P. <br /> PUMP REPLACEMENT / / State Work Done <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 .* my knowledge and belief. I WILL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G D INAL E CrION.' <br /> SIGNED TITLE <br /> (DRAW PJO PLAN ON REVERSE SIDE <br /> F WDEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASNJ/,FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY !/ DATE ZE >f <br /> r '- <br /> E H 1426 Rev. 1-74 _ 4A5 2M <br />