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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 3 746 # <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 CENSUS TRACT <br /> + Phone <br />. Owner's Name E <br /> - -I <br /> Address 7 G D City c <br /> Contractor's Name &©Act< ,OaeN oO_ ,1-AVC. License #.9.o0 q q Phoneq4�-r--M7 <br /> Zi <br /> 4 <br /> TYPE OF WORK (Check) : NEW WELL /F DEEPEN J / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / J FiTMP REPAIR / / PUMP REPLACEMENT /7 I <br /> Other I I <br /> DISTANCE TO NEAREST: SEPTIC TANK 5o, SEWER,1LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ' ' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation O <br /> Domestic/private < w !� �Dril'led Dia, of Well Casing 1i �-- <br /> ----------- <br /> Domestic/public Driven Gauge of Casing }_=--: <br /> Irrigation Gravel Pack ' Depth of Grout Seal i <br /> Cathodic Protection _ Rotary Type of Grout ' s <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal`In'stalled-By.-: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump y �` e' 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 <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 eo\or'regula.ting well-'construction. Within FIFTEEN DAIS <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' tle 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 TO GROLV4NG AND A F AL INSPE ION. <br /> : SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I <br /> APPLICATION ACCEPTED BY42 _ DATE <br /> ` ADDITIONAL COMMENTS: <br /> PHASE II GRO T INSPECTION PHAS Il FINAL INSPECTION <br /> INSPECTION BY DATE 0-' X INSPECTION BY DATE -- <br /> �. t <br />