Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> RFOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. IY7 1:771 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /�7 <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 isrmade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Riles and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ��p �(> <, fy/ _ CENSUS TRACT 02 <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL IG1/ DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK 4007 SEWER LINES- PIT PRIVY per/ <br /> SEWAGE DISPOSAL FIELD� CESSPOOL/SEEPAGE PIT �# OTHER <br /> PROPERTY LINE9WRIVATE DOMESTIC WELI,�W'PUBLIC DOMESTIC WELL G <br /> INTENDED USE TYPE__QF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Too]. Dia. of Well Excavation✓Domestic <br /> /private Brined 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: a4lone <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 (}AA?_-, _ 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUT G AND FINAL INSPECTION. <br /> SIGNED . TITLE tf <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY o DATE 42 7 <br /> ADDITIONAL COMMENTS: � a �� S <br /> PHASE II G OUT INSPECTION PHASE III/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE \ I <br /> E H 1426 Rev. - I-74 0, 17 2M <br />