Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For, OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone : (209) 466-6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-7�--5 <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued ,y�i-T1 <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 # compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and. Regulations of the San Joaquin Local -Health,District. <br /> t <br /> JOB ADDRESS/LOCATION O CENSUS TRACT, <br /> Owner's Name Phone <br /> Address : , . . Q City <br /> c <br /> Contractor's Name ' License # <br /> -33ali PhoneR35; <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/_/ RECONDITION / / DESTRUCTION /7 _ <br /> .PUMP INSTALLATION / PU1NP REPAIR /-/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 06 <br /> _ = - <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 ..A O . <br /> Industrial Cable 'Tool Dia. of Well Excavation .� <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing I <br /> Irrigation Gravel Pack Depth of Grout Seal � I <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump � � H.P. <br /> PUMP REPLACEMENT: / / State Work Done <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 /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOAN A FIN_4,L INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DVARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ��� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I SPECTION PHASZ 11,T F NAL INSPECTION <br /> INSPECTION BY DATE, INSPECTION BY DATE' /7� <br /> E H 1426 Rev. • I-74 / %77 _ 2M <br />