Laserfiche WebLink
!P SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: (I 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 :i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED * Date Issued k_w__;� <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sen' 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;Joaquin1 <br /> County Ordinance No 1862 and the Rules. and Regulations of the San -Joaquin. Local Hea1thDistrict. <br /> JOB ADDRESS/LOCATION �J <br /> CENSUS TRACT <br /> Owner's Name' ; <br /> Phone ' <br /> Address <br /> city t <br /> Contractor's Name sf <br /> License 4 2cid Phone <br /> TYPE OF WORK (Check) NEW WELL 'Z7 DEEPEN '/__ RECONDITION / DESTRUCTION <br /> PUMP INSTALLATION / _ <br /> PUMP REPAIR/ 7 PUMP REPLACEMENT % f <br /> .Other /� <br /> DISTANCE TO NEAREST: SEPTIC TANK EWE <br /> SEWER LINES PIT PRIVX... k <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITS OTHER. <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL" PUBLIC' DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION :SPECIFICATIONS <br /> Indus trialCable Tool Dia. of Well Excavation <br /> Domestic/private ,,`� Drilled Dia. of Well Casing <br /> Domestic/public _ .:y: Driven Gauge of Casing <br /> Irrigation ._^ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection'° Rotary Type o£ Grout <br /> Disposal i Other Other Information ; <br /> Geophysical Surface Seal 'Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type ,of Pump <br /> If <br /> PUMP REPLACEMENT: / State Work Done <br /> , . <br /> PUMP :REPAIR: /7 State Work Done <br />)ESTRUCTION OF WELL: � .. <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Ind '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 />&LI DRILLERS REPORT of 'the-well e-well and notify them before putting.the..well. in.use... .The above <br /> Lnformation is true to-the•best-of-my..knowledge and belief. 'I WILL CALL:'FOR 'A GROUT INSPECTION <br />'RIOR TO GROUTING 'AND..A FINAL INSPECTION. <br />)IGNED - „M _ TITLE (� <br /> i DRAW PLOT PLAN ON REVERSE SIDE r' <br /> jE FOR DEPARTMENT USE ONLY <br />'HASE I - e <br /> XPLICATION ACCEPTED BY DATE ' <br /> MDITIONAL P-OMMENTS: ip <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />:NSPECTTON BY ij DATE INSPECTION BY DATE-,� -77 <br /> E H 1426 Rev. 1-74 r i� �, _ t n.. h/75 2M <br />