Laserfiche WebLink
3 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR- FFIft- USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 `® <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �J <br /> THIS 'PERMIT EXPIRES 1 YEAR' FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Hereby madetothe 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 CENSUS .TRACT <br /> Owner's Name ' <br /> Phone <br /> Address- City <br /> I Contractor's' Name CO, , SNC License # 290$13 Phone 55-11$5 <br /> w_ .. - <br /> TYPE OF WORK (Check) : NEW WELL h71 DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �, PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITS.. • 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 lltt 1 <br /> x Domestic/private Drilled Dia, of Well Casing n <br /> E Domestic/public Driven ' Gauge of Casing - 160W -� - <br /> Irrigation . Gravel Pack Depth of Grout Seal. 501 <br /> Cathodic Protection X Rotary Type of Grout - <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t H.P. <br /> z <br /> PUMP .REPLACEMENT: / / State Work Done 1 <br /> PUMP .REPAIR: .Y _ / /._.,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 /> Iand 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE -- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � 1 <br /> APPLICATION ACCEPTED BY DATE �� <br /> ADDITIONAL COMMENTS: <br /> PHASE II G INSPECTION PHASWII/FTtjAj ,INSPECTION <br />` INSPECTION BY DATE INSPkCTION BY ATE 7 <br /> E H 1426 Rev_. 1-74 07144WX46 .?-/��78 n►4?rJ WL- 12, <br /> 12,Z:7 - . <br />