Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT al <br /> FOA+rOFFIGE USE: YYY 1601 E. Hazelton Ave. , Stockton, Calif. j <br /> Telephone: (209) 466-6781 ��- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�1- !: P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .Zy__7cf <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 0 CENSUS TRACT <br /> Owner's Name Phone <br /> ,Address Z O �7 City <br /> Contractor's Name License #6200 Phone <br /> A <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN '/-7 RECONDITION /_7 DESTRUCTION 17 <br /> PUMP INSTALLATION & PUMP REPAIR /_7 PUMP REPLACEMENT-- 17 <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, <br /> Industrial X Cable Tool'- .-"-- D.ia of W l -Exfia tion <br /> Domestic/private Drilled Dia .of Well Casing,_ <br /> --Domestic/publ1-c "'� ``'r`=�"� Drtvea Gauge of Casing" � d: � <br /> i r Irrigation Gravel Pack - ---:Depth of Grout Seal ' t <br /> i Cathodic Protection Rotary. Type of Grout 0- <br /> Disposal .� Other OtherInformation <br /> Geophysical Surface Seal Installed By P, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> F f � <br /> PUMP REPLACEMENT: / / I State Work Done <br /> PUMP :REPAIR: L_T t State Work Done <br /> 4ES-TTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> , �l her*eby -agree -to `comply with all laws-andL"°regulAtions of the SanJoaquin 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 alcove <br /> information is true to the best of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> E DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS:-.. , <br /> PHASE II GROUT INSPECT 109 - PHASE III/FINAL INSPECTION <br /> INSPECTION BY 1 DATE- INSPECTION BY DATE <br /> 'l E H 1426 Rev. 1-74 2M <br />