Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> AI'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-,;?, <br /> TH SSPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Dace IsauedAC-��7 <br /> f <br /> (Complete In Triplicate) <br /> Application is hereby made to the. San Joaquin Local Health District for a peruji to construct <br /> and/or install the work hetein described; aThis application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 a#d the Rules and Regulations of,�he San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION.. , CENSUS TRACT <br /> 3(04 <br /> Owner's Name t- Phone L <br /> Address �. --- <br /> Contractor's Name License # Phone - -Q <br /> -DEEPEN=%��--RECONDITION `/-7-DESTRUCTION--f7- <br /> ".5 <br /> .TYPE OF=WORK=4 Ghe'ck): NEW'WELL-/ _ - <br /> S <br /> PUMP INSTALLATION V PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / I <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 Gravel Pack Depth of Grout Seal C? <br /> i Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical F Surface Seal Installed B : <br /> 4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ' PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /TI State Work Done <br /> j3ES'TRUCTION OF WELL: Well Diameter Approximate Depth <br /> k Y <br /> Describe Material and Procedure <br /> f 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, -1 will furnish the San Joaquin Local Health District a <br /> I 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 GR TING ANDA INAL INSPECTION. <br /> SIGNED TITLE <br /> t DRAW PLOT PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE a <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: 31,99X5 <br /> Xr-,51 <br /> PHASE II 0 T INSPECTI0 P II FI INS ECTIINSPECTION BY DATE l INSPECTION BY TE <br /> i 1 'E H 1426 Rev. 1=I /� ��'„c '�/-S"'2���. -74 2M _-- <br />