Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: :, 1601. E. Hazelton Ave. ,' Stockton, Calif. <br /> Telephone: (209) '466-6781. . ' <br /> 91 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. . <br /> THIS, PERMIT EXPIRES1 YEAR FROM.DATE ISSUER Date Issued <br /> .x . (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 incompliance with San Joaquin <br /> and Regulations o the San Joaquin Local Health District. <br /> County Ordinance No. 1862 andothe Rules <br /> JOB ADDRESS/LOCATION <br /> r Phone <br /> Owner's- Name <br /> C City <br /> Address L <br /> License <br /> Contractor s `Mame l <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP REPAIR / / PUMP REPLACEMENT I� <br /> PUMP INSTALLATION / / <br /> Other / I i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Q PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CE SPOOL/SEEPAGE PIT OTHER h <br /> PROPERTY -LIN PRIVATE DOMESTIC WELL ISQ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial r.. --Cable Tool Dia. of Well Excavation <br /> Drilled <br /> Dia. of Well Casing, -- - <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public � f <br /> Irrigation :_-::y Gravel Pack Depth of Grout Seal <br /> Cathodic Protection y Rotary Type of Grout <br /> Other Other Information <br /> Disposal <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor H.p. <br /> Type of Pump <br /> f PUMP REPLACEMENT: / / State Work Done <br /> ;State Work Done j <br /> PUMP .REPAIR: �/ .. <br /> DESTRUCTION OF WELL: WellDiameter <br /> Approximate Depth <br /> Desctibe Material and Procedure <br /> 1 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 GROUTING AND A FINAL INSPECTION. TITLE <br /> SIGNED (DRAW PLOT PLAN ON REVERSE SIDE) - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE SL?� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE IJILFINAL INSPECTION <br /> ,. PHASE II GROUT, I SPECTION D <br /> INSPECTION BY ' DATE -7��'7 INSPECTION BY <br /> n IT 1119 Vo . 1-7!i _ - - - <br />