Laserfiche WebLink
SAN' JOAQUIN LOCAL HEALTH DISTRICT <br /> F 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 <br /> E (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 d,2 YOL -d z x . CENSUS TRACT <br /> Owner's Name * Phone g/&-Lf-f <br /> PV <br /> Address , City �- z`c3 <br /> Contractor's Name ,- License Ahone Me— = --f- <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION'/ / PUMP REPAIR '/ / PUMP-REPLACEMENT /? S <br /> Other-/ _/ -- . _ t• ` -s_�-.Y�., - <br /> M r t <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 i 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 /> PUMP•,REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter r Approx'mate 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 f my work-'on anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS PO T of the well and notify them before putting the .well in use. The above <br /> information is tr a to the bes f my n ge and belief. I WILL CALL R A GROUT INSPECTION <br /> k PRIOR TO GRO A 5 EC <br /> SIGNED � - TITLE <br /> DRAWP� T PLAN 'ON RE FRSE SIDE <br />' <br /> FOg DEPARTMENT USE ONLY <br />� PHASE I -Z <br /> APPLICATION ACCEPTED BY DATE �5"/7 <br /> ADDITIONAL COMMENTS: 11 <br /> fPHASE II GROUT INSPECTION PHASE III/FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> i �� H�S'`7 9 @ J i�S P/tel• . <br /> E H 142 Rev. 1-74 ,� <br /> 3/76 2M <br />