Laserfiche WebLink
JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$rOFFIGE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' I Telephone: (209) 466-6781 J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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 7 7 CENSUS TRACT <br /> 1 <br /> Owner's Name / Phone <br /> i <br /> Address 1.,,rr�� City . <br /> Contractor's Name [� License Phone <br /> TYPE OF WORK (Check):' NEW WELL 'IF DEEPEN '/-7 RECONDITION /-7 DESTRUCTION %j <br /> PUMP INSTMATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other,/ / ""- <br /> r <br /> DISTANCE TO NEAREST: SEPTIC-TANK ;225- SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL 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 /> Domestic/private I Drilled Dia. of Well Casing, ? .`. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> f Cathodic Protection i Rotary Type of Grout <br /> Disposal � I Other Other Information <br /> Geophysical Surface Seal Installed B :; <br /> PUMP INSTALLATION*- '.� _ <br /> N• � ,Contractor i : ; Al. _ s, <br /> Type of Pump H.P. <br /> . r <br /> PUMP REPLACEMENT: / / State Work�Done' <br /> PUMP !REPAIR: <br /> � /� -State Work Done <br /> 4E&TRUCTION OF WELL: Well Diameter R 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 qnd belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR GR TI AND A INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r DATE <br /> ADDITIONAL COMMENTS: pyo,f <br /> PHASE Ir GROUT INSPECTION PHASE I I FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION. BY DATE <br /> s ;1-77 EB 1426 Rev. -74 �� <br /> s �7 4 2M <br />