Laserfiche WebLink
_SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �r".OF�.OFFICE USE; 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 I YEAR FROM DATE ISSUED <br /> a /�-;r/� (Complete In Triplicate) Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> i 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 /> s <br /> ` JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br />[.. Owner's Name I <br /> F Phone <br /> Address <br /> Lill [Y City <br /> —.- <br /> Contractor's Name <br /> License # , r�hone <br />, TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION <br /> PUMP INSTALLATION PUMP REPAIR /� DESTRUCTION /_7/ / /�/ PUMP REPLACEMENT /� <br /> .-.. <br /> Other . <br /> DISTANCE TO NEAREST; SEPTIC TANKp <br /> ® SEWER LINES f-- PIT PRIVY Q <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESOTTIC <br /> HER <br /> INTENDED USE WELL <br /> 'TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIO S <br /> Cable Tool, . Dia, of Well Excavation <br /> Domestic/private Drilled � � � <br /> Domestic/public Dia. of Well Casing l <br /> Driven Gauge of Casing <br /> Irrigation --� ` { <br /> Gravel Pack Depth of Grout Seal � '��!' <br /> Cathodic Protection Rotar <br /> MA Disposal y Type of Grout <br /> Other Information <br /> '"t�Geophysical Other I <br /> ---- <br /> ~� Surface Seal Installed By: gip. <br /> P INSTALLATIO /+2bV f> o a _rL, 2!C2r, N d <br /> N• Contractor 'A ' <br /> Type of; Pump � R <br /> _ H.P. <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> fill <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> M <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 DA 5 <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 4ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Lriformation. is true to the best of my knowledge and belief, F <br />'RIOR TO GROUTING A FINAL PECTION. g I WILL CALL FOR A GROUT INSPECTION <br /> iIGNED - <br /> TITLE <br /> (DRAW PL AN ON REVERSE SIDE) -- <br />'HASE I FOR DEPARTMENT .USE ONLY <br /> APPLICATION ACCEPTED BY <br /> IDDITIONAL COMMENTS: DATE p �� <br /> PHASE II GROUT INSPECTION PHASE II /FIN INSPECTION <br /> NSPECTION BY DATE . INSPkCTIONBY <br /> •'` DATE <br /> E_.H42b Rev. 1--74 , i <br />