Laserfiche WebLink
F 1JOAQUIN LOCAL HEALTH DISTRICT <br /> EOF�"OFFIL USE: 1601 Hazelton Ave. , Stockton, Cali. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMPY> RMI.T .._I'_ermit-No-2—y- = <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 1-J <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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONACENSUS TRACT <br /> Owner's Name Phone �j� �, <br /> Address City <br /> Contractor's Name 1v .License Phon -- �� <br /> _ I <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> OtherAA <br /> ,. <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 /> INE ED USE TYPE OF W LL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> D stic/public Driven Gauge of Casing <br /> rrigation 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: <br /> 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 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 DAIS <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 welland notify them before putting the well in use.. The above <br /> information i true to the t of my of and belief. I WILL FOR A GROUT INSPECTION <br /> PRIOR TO GRO NG AN A F. I P CT ON, <br /> SIGNEDTITLE <br /> {DLAE PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE //'r��'' 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY PATE +��_T <br />� �E H 1426 Rev. 1-74 <br />