Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> FOA-OF ICE USE: 1601 E. Hazelton Ave.. , Stockton, Calif. <br /> t, 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/p <br /> (Complete In Triplicate) " # <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct i <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 _.. jQ 4L !2 11'ktj L- eld an� CENSUS TRACT <br /> Owner's Name u ca.,, t v, a Phone / <br /> Addressa o �-yG ' rte{ y e T Q�.� City _ <br /> Contractor's Name s�w License # 1V-2_Yrhone <br /> i <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN /� RECONDiTiON /� DESTRUCTION /- <br /> PUMP INSTALLATION PUMP REPAIR Ag PUMP REPLACEMENT /7 <br /> Other /7 E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I PIT PRIVY <br /> 'SE>wAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> K PROPERTY LINE --PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL I CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. ,of Well Excavation <br /> Domestic/private Drilled Dia. :of Well Casing `f1 <br /> f Domestic/public Driven Gauge of Casing �O <br /> ( F Irrigation Gravel Pack Deptt of Grout Seal <br /> [ ' Cathodic Protection Rotary Type4of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �- .....�_ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: State Work Done �1-�--- <br /> I <br /> pES•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 /> I 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 knowled nd-b_lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG U NG AND A FINAL INSP I N, aC <br /> SIGNED , TLE <br /> (DOW T PLAN-ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY DATE 16-&,'K/ <br /> t E H 1426 Rev. 1-74 1-74 2M <br />