Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE'USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR ,FROM DATE ISSUED Date Issued <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 his aPPli+- tion is wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and he Rules] c� Regu�atiofil the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONi2j' <br /> CENSUS TRACT <br /> Owner's Name tf <br /> Phone <br /> Address <br /> city <br /> ,r <br /> Contractor's Name License #� cthan % ' <br /> TYPE OF WORK (Check) : NEW WELL /? DEEPEN /-T RECONIDITION /- DESTRUCTION /- <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT ' <br /> Other / / f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ��Ij <br /> PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT V OTHER <br /> PROPERTY LINE - PRIVki <br /> ATE DOMESTICIWELL- 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/publicDriven .., Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Te� of Grout <br /> Disposal Other _ Otyhper If <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ; <br /> H.P. '�- <br /> PUMP REPLACEMENT: State Work Done' <br /> !/ <br /> PUMP--REPA-M-- _ , <br /> /� State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter , Approximate Depth <br /> Describe Material and Procedure {r -�---- <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`jwell 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 beforeljputting 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 TOG !TING AND A FINAL INSPECTION. <br /> SIGNED I TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> ARTMENT %E ONLY <br /> PHASE I FOR DEP <br /> APPLICATION ACCEPTED BY C _ DATE <br /> Lz <br /> ADDITIONAL COMMENTS: V <br /> PHASE II GROUT INSPECTION P NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H-1426 Rev. 1-74 <br />