Laserfiche WebLink
. V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORf'OFFICE USE: 4601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> j APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued Za,..zS 7,a <br /> I (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 R gulations o he San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION . CENSUS TRACT <br /> Owner's Name Phone F0 ! <br /> Address' City ' <br /> ���•� <br /> ,,Contractor's Name � icense # Phone <br /> TYPE OF WORK (Check) : NEW WELL/? DEEPEN '/_7 RECONDITION /_7 DESTRUCTION /7 ` <br /> PUMP INSTALLATION PUMP REPAIR /_7 PUMP REPLACEMENT %7 <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 � <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing v <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 /> PUMP `REPAIR: /_7 mState Work Done <br /> EES�ION 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 t the best of my.knowledge and belief. I WILLea FORA.GROUT INSPECTION <br /> PRIOR TO GR UTING AN INAL INSP CT ON. <br /> SIGNED TITL <br /> IDE <br /> (DRAW PLOT PLAN ON REVERSE S <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY /' DATE 7�' <br /> ADDITIONAL COMMENTS: t <br /> PHASE ,1I GROUT INSPECTION PHASE,,VVFINAL INSPECTION <br /> i INSPECTION BY DATE INSPECTION BY ATE <br /> r <br /> k1 ^E H 1426 Rev. 1-74 1-74 2M <br />