Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> 7� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T�y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3- <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. 1.862 and the les and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I .ENSUS TRACT <br /> Owner's Name Phone 3 G <br /> Address - L0_1-A4 l - City <br /> Contractor's Mame 45 License 1146-137 3 Phone3, <br /> a <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION DESTRUCTION /-7 _ (A <br /> AL <br /> PUMP INSTLATION / / PUMP REPAIR ,p ­PUMP REPLACEMENT <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 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: T <br /> PUMP INSTALLATION: Contractor <br /> f <br /> Type of Pump ' - H.P. d <br /> PUMP REPLACEMENT: / / State Work Done <br /> e � <br /> PUMP .REPAIR: CC/ 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..o.f__Calif,ornia-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 rue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPEC ION <br /> PRIOR TO GROUTOG OD A LX INSPECT N. <br /> SIGNED TITLE _ <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: 4 r-2�gs <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> E H 1426 Rev. - 1-74 <br />