Laserfiche WebLink
SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> F06.iOFFICE USE: /1,601 E. Hazelton Ave. , Stockton, Calif. E <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9-�ia <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date, Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son Joaquin Local"llealth 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 /> a. <br /> JOB ADDRESS/LOCATION ,S CENSUS TRACT <br /> Owner's Name Phone ' . 1,3-0,2Z <br /> Address City <br /> Contractor's Name � <br /> License 02?j Phone <br /> TYPE OF WORK (Check): NEW WELL /f DEEPEN/? RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR/-7—PUMP REPLACEMENT <br /> Other <br />'DISTANCE TO NEAREST:' SEPTIC TANK' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER t <br /> PROPERTY,-LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 6\ " <br /> INTENDED USE r TYPE OF WELL CONSTRUCTION SPECIFICATIONS U <br /> Industrial Cable Tool Dia. of Well Excavation <br /> i <br /> Domestic/private _._._r._. Drilled Dia. of Well Casing <br /> Domestic/public Driven' Gauge of Casing <br /> Irrigation ,I' Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 1 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' � <br /> i! <br /> PUMP REPLACEMENT: . State Work Done <br /> PUMP .REPAIR: � %r% State YWork Done <br /> t <br /> DESTRUCTION OF WELL: W611 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 anew 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 ROU3'ING AND A FINAL INSPECTION. <br /> SIGNED __ TITLE <br /> li (DRAW PLOT PLAN ON REVERSE SID�� <br /> PHASE I <br /> FOR, DEP MENT USE ONLY <br /> � :� ,�y "-"' <br /> APPLICATION ACCEPTED BY of/ DATE . -70 <br /> ADDITIONAL COMMENTS: <br /> X�_ <br /> PHASE II. GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY IDA 1A DATE INSPECTION BY DATE (� <br /> EdH 1426 Rev. 1-74 L/7< W `� <br />