Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi;,OFFI.CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -398 <br /> THIS PERMIT EY►PIRES 1 YEAR FROM DATE ISSUED Date Issued <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 W, •� � CENSUS TRACT <br /> Owner's Name Phone <br /> Address ! 3 -73 City <br /> Contractor's Name 001License Phone J 3 <br /> TYPE OF WORK (Check): NEW WELL '/7 DEEPEN •/_7 RECONDITION f7 DESTRUCTION 1-7 <br /> PUMA INSTALLATION / / PUMP REPAIR-1-7—PUMP REPLACEMENT <br /> Other / / . . . . . . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY, � PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE FTYPE. OF WELL'-,;„ CONSTRUCTION SPECIFICATIONS r <br /> Industrial. Cable ToolEDep <br /> Dia. of,Well Excavation <br /> - ' Domestic/private Drilled 1 Dia. of Well Casing <br /> Domestic/public Driven Guge .of Casing <br /> Irrigation Gravel Packth !of Grout Seal <br /> Cathodic Protection a RotaryTy� af'Grout <br /> A <br /> Disposal ;_ ,other ----�-Other Information ' <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor �� p <br /> Type of Pump t H.P. l Lr <br /> PUMP REPLACEMENT: . /t�` S tate Work Done 6,11a <br /> PUMP :REPAIR: / tatd.•Work Done - <br /> DESTRUCTION OF WELL: Well iameter Approximate Depth <br /> Desctbe 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting.the..well. in.use.. . The above <br /> information i rue the-best of—my—knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO G AN t A FIX9 INSPECT , <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> ..FOR DEPARTMENT USE ONLY <br /> � ," � �. r / <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> !',I PHASE II GROUT INSPECTION PHAS§4141MINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY .; DATE <br /> E H 1426 Rev. 1-74 r' - h/75 2M <br />