Laserfiche WebLink
i t <br /> a SAN -3OAQUIN LOCAL HEALTH DISTRICT <br /> FOL;OFFICE 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 I YEAR FROM DATE ,ISSUED Date Issued <br /> (Complete In Triplicate) <br />� ' Applicetion 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 /> IG JOB ADDRESS/LOCATIONS W' CENSUS TRACT <br /> Owner's Name �J � � Phone hi�2- <br /> Address City <br /> Contractor's Name c 4 .-C,v, <br /> License :C?C! honed ._ ®6P,G <br /> TYPE OF WORK (Check): NEW WELL '_0 DEEPEN -/7 ..RECONDITION L DESTRUCTION <br /> PUMP INSTALLATION -E/ PUMP REPAIR/� FUMP REPLACEMENT J T <br /> 4- <br /> 1 Other #%/ � . . . . . . <br /> DISTANCE TO NEAREST: SEPTICiTANK 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 /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public I Driven ,!. Gauge of Casing <br /> Irrigation Gravel Pack- Depth of -Grout Seal 1 <br /> Cathodic Protection ice` Rotary : 0. t Type of Grout <r <br /> Disposal - I Other Other Information <br /> Geophysical Surface Seal Installed Bv: -- �- <br /> PUMP INSTALLATION: . Contractor <br /> Type ,of Pump; H.P. - <br /> PUMP REPLACEMENT: / . State Work Donee <br />' 'PUMP 'REPAIR. <br /> /-7 State Work Done <br /> RE&TRUCTION OF WELL: Well Diameter <br /> Approximate Depth L <br /> Describe Material and Procedure <br /> :I hereby agree to comply withlall laws -and' <br /> regulations of the .San Joaq%iin Local Health District <br /> And the State of California pertaining to or regulating well':.construction. Within-FIFTLEN DAYS <br /> after:.'completion of my work on a new well, I will furnish the San Joaquin Local :Health District a <br /> aWELL DRILLERS REPORT of :the w' 11 and :notify them before putting..the..we11. 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 TOG TING 'AND FINAL IINS PECTION. <br /> SIGNED TITLE t <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I w <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL <br /> PHASE II GROUT INSPECTION ,_ PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE ,1NSPECTION,'BY DATE 2G <br /> E H 1426 Rev. 1-74m <br />