Laserfiche WebLink
SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> EOE OFFICE USE 1601 E. Hazelton Ave. $ ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 ��' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S— <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin--L-6cal 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 ulatio s of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION CENSUS TRACT _ <br /> Phone <br /> Owner's Name <br /> Address City 1 ,-- <br /> Contractor's Name ,, .. _.License d -715 Phone LEI <br /> i <br /> TYPE OF WORK (Check): NEW WELLDEEPEN._/7/ RECONDITION / / DESTRUCTION I7 <br /> PUMP INST�TION / / PUMP REPAIR / / PUMP REPLACEMENT -7 <br /> Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK _AEajL-- SEWER LINES _J'Q SPIT PRIVY -- <br /> SEWAGE DISPOSAL FIELD 5a f.- CESSPOOL/SEEPAGE PIT BOTHER <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 /> '� <br /> f Domestic/Private Drille'V7 Dia. of Well Casing _ — \ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal ` <br /> Cathodic Protection ___3:-Z,_ Rotary Type of Grout �I T _ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B ,..f <br /> PUMP INSTALLATION: Contractor. <br /> k Type of Pump H.P. _ <br /> • <br /> PUMP REPLACEMENT: State Work Done<./ / <br /> ' PUMP`-.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> It, <br /> Describe Material and Procedure <br /> 1I hereby agree to comgly.'with all laws and regulatioris of the\an Joaquin Focal Health District <br /> and�he 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 /> WDLL DRILLERS REPORT of the well a_ notify them before putting the..well in use. The above <br /> in .airmati is true to the bei-5;.of my knowledge a_nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> ,PRIOR T® GR TI AND INAI3 SPIE --- -.� , <br /> t. SIGNED TITLEt <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> �PHA�I DATE <br /> , APPLICATION ACCEPTED BY R <br /> ADDITIONAL COMMENTS <br /> � PHASE II G UT INSPECTION PHA /F NAL INSPECTI N <br /> INSPECTION BY ATE _ INSPECTION BY DATE 4 <br /> t0124 el�eU <br /> �r > <br /> . 1177 2M <br />