Laserfiche WebLink
,��/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EFO1R,_,'=0FFIC=EU=SE-. ' ��" 1601 E. Hazelton Ave. , ,Stockton, Calif. <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 /> (Complete In Triplicate) 2 Y7 - /f'0 -0) <br /> Application is 4ereby 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/LOCATION1J�,� p «. TRACT <br /> Owner's Name 0 V i R Q' <br /> Phone <br /> Address Dkl 4 - f <br /> City <br /> 3 <br /> Contractor's Name Q License /(Phone <br /> r J <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation O <br /> g Gravel Pack Depth of Grout Seal � <br /> Cathodic Protection Rotary Type of .Grout G1 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> r <br /> PUMP REPLACEMENT: % State Work Done ) f <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 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 and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FINAL INSPECTION. <br /> SIGNED ; TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY /' DATE <br /> ADDITIONAL COMMENTS: / <br /> PHASE Ii GROUT INSPEC__TION `f PHA I/ NAL INSPEC 0 <br /> INSPECTION BY eft DATE INSPECTION BY DATE <br /> V � <br /> E H 1426 Rev. 1--74 1177 2M <br />