Laserfiche WebLink
- - -- SAN JOAQUIN LOCAL HEALTH DISTRICT --- <br /> FOEiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. k <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. wp <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L_,.3-7 <br /> (Complete In Triplicate) <br /> Application-is hereby made to the San Joaquin Local Health District for a pel.*mit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquini <br /> County Ordinance No18b2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> D �DO /V Sea S <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> F <br /> Owner's Name Phone <br /> Address 6 A �. City <br /> Contractor's Name License #���one <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/_7 RECONDITION /_7 DESTRUCTION fT <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other 17 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4,-Ga5le Tool Dia. of Well Excavation <br /> 4,--ftme s tic/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 /> T11- <br /> -Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> t <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP'-REPAIR-;--'-"""' 1 /—Stat6_Work Done <br /> PES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> F <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 GR a D INSPECTIM. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY s DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE III/FINAL INSPECTION <br /> k INSPECTION BY DATE . INSPECTION BY DATE /..o <br /> � t E H 1426 Rev. 1-74 1-74 2M <br />