Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF 9F CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP `PERMIT Permit No. <br /> TRIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made do 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 /> i <br /> JOB ADDRESS/LOCATION ,dr CENSUS TRACT <br /> 11 <br /> Owner's' Name Phone <br /> 7 Address I. . <br /> City <br /> Contractor}s NameC License �� • . Phone <br /> T77_07 <br /> S <br /> TYPE OF WORK (Check) ; NEW WELL/ DEEPEN '/—/ RECONDITION DESTRUCTION /_7 <br /> PUMP !INSTALLATION-/j/ PUMP 'REPAIR /�cf PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE #TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i Industrial Cable Tool Dia. of Well Excavation <br /> 'Domestic/private i 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: <br /> PUMP INSTALLATION: Contractor <br /> :.. TYpe=of Pump H.P. <br /> PUMP REPLACEMENT: / / f� State Work Done <br /> PUMP .'REPAIR-: ZLC/ State Work •Done <br /> DESTRUCTION OF WELL: Well Diameter A 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 wel'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 thewell in use. The above <br /> information is true to the;best m know-lege and belief. I WILL CALL• FOR A GROUT INSPECTION, <br /> � . PRIOR UTING D A FINAL NSP I <br /> SIGN. ' TITLE. <br /> D W : PI:ADT NtSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I j <br /> APPLICATION ACCEPTED BY �i DATE ? -17 _ <br /> ADDITIONAL COMMENTS: �' - ---- — <br /> PHASE II ROUT INSPECTION PHASE III/FINAL INSPECTIOUrt <br /> INSPECTION BY tDATE INSPECTION BY DATE f/ , <br /> E.H 1426 3/76 <br /> Bev. 1-74 <br />