Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF .OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 46.6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -j3_,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 is made in compliance with San Joaquin <br /> County Ordinance No. 1862 ana the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION W CENSUS TRACT <br /> Owner's Name Phone <br /> Address - � <br /> r <br /> City <br /> Contractor's Name L FJ License # /9/ Phone <br /> ; <br /> TYPE OF WORK (Check) : _ NEW..WELL /;AEE� N__//RECONAITTON_ / / DESTRUCON /- <br /> _r • PUMP .INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT P� <br /> Other/ / <br /> .-DISTANCE TONEAREST: 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 /> %�}omestic/ -iv ate Drilled Dia. of Well Casio <br /> W <br /> n <br /> Domestic/public: Arzven Gauge of Casing <br /> Irrigation i Gravel Pack Depth-`of Grout' Seal <br /> Cathodic Protection i Rotary Ty'2 oft- Grout <br /> Disposal ` k Other Other•::Information?" i <br /> Geophysical Surface Sea17Installed B <br /> PUMP INSTALLATION: ,. Contractor ,�- <br /> �.�, <br /> Type p <br /> e Yof Pum H.P. <br /> PUMP REPLAGEIIENT,: p � State Work Done _ <br /> a� • <br /> t PUMP .REPAIR.•..• Y �' R �� - <br /> j .7\ �� /,;/ � !Mate Work Done, 4 <br /> DES-TRUCTION 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 i <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 puttingthe well in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOJt A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A NALl SPECTION. <br /> SIGNED TITLE! <br /> I (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY I DATE�,�' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GgOVV I SPECTION P EI .!/FI AL INSPECT1,ON <br /> INSPECTION BY DATE INSPECTION BY f ; DATE rt <br /> E H 1426 `•'Rev. .1-74 7� <br />