Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZE-id-Y2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z-,L 28- <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 <br /> ,LRe tions of t e San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � G� <br /> CENSUS TRACT <br /> Owner's Name Phone .� C <br /> Address City N <br /> Contractor's Name License Phone �[1 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION __/ DESTRUCTION /_7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /_7 <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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public. -- .. -Driven - Gauge of -Casing-- <br /> Irrigation <br /> f Casing-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 . T ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / 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 GROUZIA AND A FINA S TION <br /> SIGNED4�ZLA <br /> TITLE <br /> DRA PLOT PLAN ON REVERSE SIDE) <br /> FO PA TMENT JJSE ONLY <br /> PHASE I p <br /> APPLICATION ACCEPTED BY DATE �(7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION SE III/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY w . �. DATE y 24 ,�V <br /> 2M- <br /> E H 1426 Rev. , 1-74 <br />