Laserfiche WebLink
SAN JOAQUIN LOCAL HEAL ISTRICT <br /> =7087OFFICE USE: ., 1601 E. Hazelton Ave. <br /> Stockton, 'Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP' PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued `T t <br /> (Complete In ate)JI <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the wo k herein described. This application is made in compliance with San Joaquin,; <br /> County Ordinance No. the Rules and Regulations of he San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATI CENSUS TRACT <br /> Owner's Name Phone <br /> Address ,57(' # �� City � s <br /> ' <br /> Contractor'a Nameicense A Phone <br /> a <br /> TYPE OF WORK(heck): NEW WELL / DEEPEN /7RECONDITION %j DESTRUCTION <br /> PUMP INSTALLATION /7 PUMP REPAIR 1-7 PUMP REPLACEMENT /7 ` <br /> Other 17 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 I Cable Tool Dia. of Well Excavation <br /> t/ Domestic/private i Drilled Dia. of Weil Casing <br /> Domestic/public i Driven Gauge of Casing N <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection ✓ Rotary Type of Grant' J <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed Bu <br /> it ' <br /> PUMP INSTALLATION: Contractor j <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done �! <br /> PUMP ,.REPAIR: State Work Do e� <br /> ES+TRUCTION OF WELL: Well Diameter Approximate Depth r <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 puttingthe well in.use.. The above <br /> information is true to the-best of- my knowledge and belief. IIJWILL CALL FOR A -GROUT INSPECTION � <br /> PRIOR TO GROUTING AND A FINAL I PECTION. fl <br /> SIGNED TITLE { <br /> D PLOT PLAN ON REVERSE`E.SIDE <br /> FOR DEPARTMENT USE ONLY 5 <br /> PHASE I <br /> AP ` <br /> PLICATION--ACCEPTED BY U DATE <br /> ADDITIONAL COMMENTS: h <br /> PHASEjI GROUT INSPECTION P I FINAL INSPECTIO <br /> INSPECTION BYDATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 1-7 4 2M �i rf <br />