Laserfiche WebLink
b6s 0 /1-Z oGa,. F/ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. q <br /> THIS PERMIT EXPIRES 1 -YEAR; FROM,DATE ISSUED Date Issued�q <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 Joaquin <br /> County Ordinance No 1862 and. the Rules and Regulations of the San- Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION c CENSUS TRACT ' . <br /> 444 <br /> Owner's Name Phone <br /> Addresscity <br /> --- <br /> Contractor's Name License 0�ohone <br /> i <br /> z <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION-/—/ DESTRUCTION /7 6- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKZ SEWER LINES / PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESPOOL/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 ::::7�rilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal [j <br /> Cathodic Protection Rotary Type of Grout ��,� O44 <br /> Disposal Other Other Information P� <br /> Geophysical Surface Seal Installed By: <br /> { <br /> PUMP INSTALLATION: Contractor <br /> Type' of Pump H.P. T <br /> W <br /> PUMP REPLACEMENT: / /. State Work.Don.e " <br /> PUMP .REPAIR: /y% •� State Work Done�.� • <br /> DESTRUCTION OF WELL: Well Diameter " ' �w ! ��. �.,.. ,`. '3 , Approximate Depth f <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED 4 TITLE /r9`3f <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: f <br /> PHASE II GROUT INSPECTION %e-; PHAS III/FINAL INSPEC ON <br /> INSPECTION BY DATE -7 INSPECTION BY DAT <br /> 4�-E H 1426 Rev. • 1 <br />