Laserfiche WebLink
i <br /> SAN 30AQUIN LOCAL HEALTH DISTRICT <br /> FOR!OFFICE USE: 1601. E. Hazelton Ave. , '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 <br /> (Complete In Triplicate) r <br /> 'Application is hereby made to`the San Joaquin Local Health District for a permit to construct l <br /> and/or install the work hereiii described. This application is made in compliance with San Joaquin ? <br /> County Ordinance No. 1862 andithe Rules and Regulations of the San Joaquin Local Health District. i <br /> s <br /> JOB ADDRESS/LOCATION, CENSUS TRACT <br /> Phone <br /> Owner' s Name � <br /> r <br /> Cityt 7 -.. -� <br /> Address <br /> License Phone C�' <br /> Contractor's Name s <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN -7 RECONDITION /? DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENT I <br /> Other�/ ! <br /> jSTANCE TO NEAREST: SEPTIC TANK � SEWER LINES S 2 PIT PRIVY \ <br /> SEWAGE,DISPOT9L FjIELD CESSPOOL/SEEP�GE PIT OTHER <br /> PROPERTY <br /> LINEA PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> r INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation d <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 /> Geophysical I Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type `of Pump <br /> t PUMP REPLACEMENT: / / State Work Done <br /> E PUMP '.REPAIR: / .tState Work Done <br /> ' ES�TRUCTION OF WELL: WelliDiameterApproximate Depth s <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 putting-the-well in-use.. The above <br /> information is trthe-best of my.knowled a nd belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTIN AND FINAL INSPECT <br /> SIGNED TITLE <br /> (DRAWAr PLOT LAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS: } <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> '1 <br /> 1x74 2M <br /> E H 1426 Rev. 1-74 <br />