Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 �6-31p <br /> APPLICATION FOX WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I. 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. 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 Cf. � CENSUS TRACT <br /> Owner's'Name r Phone Uf <br /> Address City <br /> s Name - <br /> , License �'�a Phone <br /> Contractor <br /> TYPE OF WORK (Check) : NEW WELL -/7 DEEPEN `/7 RECONDITION /_T DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REP / / PUREPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 R) <br /> Industrial <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/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 /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> f PUMP'.' : /-7 State Work Done <br /> I E �TRUCTION OF WELL: Well Diameter Approximate Dep h �L <br /> Describe Material and Procedure <br /> I her a e to comply with all laws d 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 <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 CAW FOR A GROUT INSPECTION <br /> ► PRIOR TO GROUTING AND FI AL INS; CTION. y <br /> SIGNED TITLE �u ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY / <br /> PHASE I r / DATEy <br /> � APPLICATION ACCEPTED BY (/1/ --- <br /> i ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE INAL SPECTION z 7� <br /> INSPECTION BY DATE INSPECTION BY TE <br /> 't E H 1426 Rev. 1-74 1-74 2M - <br />