Laserfiche WebLink
. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '� 77 <br /> (Complete In Triplicate) <br /> Application is hereby de 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 /> l., <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> k <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone %71 s <br /> Address City <br /> Contractor's Name License # Phone ' <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN / / RECONDT QN _ DES �Tj <br /> f <br /> PUMP INSTALLATION/ / PUMP REPAIR PUMP T <br /> 1 <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 <br /> Domestic/private Drilled Dia. of Well Casing ' <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 By:_ <br /> PUMP INSTALLATION: Contractor <br /> -y ` f Pump (} H.P. <br /> _.L tate Work Done <br /> PUMP REPLACEMENT: . / �r <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 /> in is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOGR TING AND A FIN INSPECT N. <br /> SIGNEDA 11L, <br /> TITLE <br /> D PLAN ON REVERSE SIT ,:.. 7$-EF <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Ir <br /> APPLICATION ACCEPTED BY DATE <br /> k ADDITIONAL COMM$NTS: <br /> PR&SE II GROUT INSPECTION PHASE III/FINAL INSPECTION .. <br /> INSPECTION BY DATE INSPECTION BY DATE y ~ <br /> V76 <br /> E H 1426 Rev. 1,74 <br />