Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0% OFFICE USE: 1601, E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z <br /> THIS PERMIT EXPIRES 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 an hRule�. a d �gt-i.o of toe San Joaquin Local Health District. <br /> ..�,� <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address 4a,_U:rza� City <br /> Contractor's Name License # 0/aO.ZPhone <br /> TYPE OF WORK (Check) : NEW WELL/? DEEPEN 7 RECONDITION 1-7 DESTRUCTION /f <br /> PUMP INSTALLATION -/i` PUMP REPAIR -/-7-pump REPLACEMENT /? ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Ilk <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 /> ,�bomestic/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 'B : <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. - <br /> w <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: Work Done/ / State <br /> _ s <br /> DESTRUCTION_OFWELL: 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 anew 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 GROUUM AND A iN INSPECTION. <br />° SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE}-,,' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY 441 DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE Il;/VMAL SPECTION <br /> 'INSPECTION BY ATE INSPECTION BY TE <br />