Laserfiche WebLink
JOAQUIN LOCAL HEALTH DISTRICT <br /> F0—F70FFT-Z USE: 160,E Hazelton Ave. , Stockton, Cal <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 /> F (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 /> Owner's Name IL <br /> Phone <br /> NAddress ED - City <br /> Contractor's Name License lP � Phon <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /% RECONDITION / / DESTRUCTION /_7 <br /> qq PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> I' Other / / — <br /> '' T - C" <br /> DISTANCEiITO 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 /> INE ED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Do C <br /> � stic/public � Driven Gauge of Casing et— <br /> rrigation Gravel Pack Depth of Grout Seal ZIP <br /> Cathodic Protection Rotary Type of Grout r' <br /> Disposal Other Other Information N <br /> Geophysical Surface Seal Installed By: ` <br /> _ el <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> > PUMP REPAIR: / / State Work Done C <br /> 41 <br /> DESTRUCTION 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 DA .S <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 /> informatio�itrue to the �of my knowledge and belief. I WILL C FOR A GROUT INSPECTION <br /> PRIOR TO GRG AN A F ICT ON. <br /> SIGNED TITLE <br /> (D PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 'PHASE I <br /> APPLICATION ACCEPTED BY DATE 1�r�Q -` 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> YINSPECTION BY DATE INSPECTION BY ATE _ <br /> t�v <br /> -:E H 1426 Rev. 1-74 <br /> 1/77 2M <br />