Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh;OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T�t-1 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued -7`s` <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 '�� 1 ,� A 6: '' CENSUS TRACT - <br /> Owner's Name Phone <br /> Address 6 0 City ' G �l <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 17 RECONDITION /"j DESTRUCTION f7 R <br /> PUMP INSTALLATION /—/ PUMP REPAIR/� PUMP REPLACEMENT 17 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK -7- 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 Cable Tool Dia. of Well Excavation- <br /> K_ 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 �c- <br /> -Disposal Other _ Other Information <br /> Geophysical Surface Seal Installed By:_ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well 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 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 G ING AND A V1 I SPECTION <br /> SIGNE <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) { <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _._._,...,. T -5',�� <br /> APPLICATION ACCEPTED BY DATE ' !� 7r <br /> ADDITIONAL COMMENTS: ",77,7 <br /> PHASE II ROUT INSPECTION PHAS I-1 aNAL INSPECTI N <br /> INSPECTION BY d= DAT�E/� ,Z a p7 INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> - ✓ h/75 2M <br />