Laserfiche WebLink
- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I F0 OFFI -E 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 1-YEAR FROM DATE ISSUED Date Issued <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 CENSUS TRACT 1 <br /> Owner's Name q �� Phone 931'35- ee y <br /> Address er%0 a City ;S` 'a <br /> Contractor's Name License # Phone <br /> 1 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_/ DESTRUCTION -)�_;r <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <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 X . <br /> Industrial Cable Tool Dia, of Well. Excavation <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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ,Typejof Pump H.P. <br /> PUMP REPLACEMENT: / / `State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> lr <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Ma rial and Procedure �,vi 0 <br /> Q..h <br /> U r" ac_P <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 "cons,truction. 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 GROUTING AND A FINAL INSPECTION. <br /> SIGN TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) - <br /> FQRDEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE l <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE/II /FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Pc-,u- , 1_7L <br /> 6/7.7 - 2M � <br />