Laserfiche WebLink
Cb h SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFF E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> iM Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��,' <br /> iM <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z__ � <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - a 2 1' CENSUS TRACT <br /> Owner's Name / Phone <br /> Address <br /> City <br /> Contractor's Name License <br /> 6 ill <br /> TYPE OF WORK (Cl�ieck): NEW WELL /? DEEPEN /_/ `RECONDITION /_7 DESTRUCTION <br /> I PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /J --- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY \' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <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 <br /> Cathodic Protection Rotary Type of Grout <br /> —Disposal , Other Other Information <br /> Geophysic-all <br /> ` Surface Sear Installed By: <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump H.P. V <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: <br /> State Work Done _ C <br /> ESMUCTION OF WELL: Well Diameter � w <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree- to comply with all lana 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 GR UTING AND A FINAL INSPECTI <br /> SIGNED . <br /> �a. ITLE <br /> (D LOT PLAN ON RSE SIDE <br /> I� FOR DEPARTMENT USE ONLY <br /> t PRASE I <br />`APPLICATION ACCEPTED BY DATE -- k <br /> ADDITIONAL COMMENTS: — <br /> zz <br /> _PHASE II GROUT INSPECTION PHAS III F NAL INSPECTION <br /> INSPECTION BY ij -' DATE INSPECTION. BYDATE <br /> '44 <br /> E H 1426 Rev. 1-74 1-74 2M <br /> . :9 <br />