Laserfiche WebLink
` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USe: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is here7by 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 /> r JOB ADDRESS/LOCATION J / T CENSUS TRACT <br /> Owner's Name Wj / � Phoner � <br /> Address / City <br /> onf <br /> Contractor's Name CJ License #4 eoPhone D ' <br />[ TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_7 <br /> i Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, .-PIT PRIVY <br /> SEWAGE DISPOSAL FIELDS ' tCESSP00L/SEEPAGE PIT .' ' `OTHER <br /> PROPERTY-LI-NE-- PRIVATE DOMESTIC WELL- " ' PUBLIC DOMESTIC WELL <br /> INTENDED USE ' ` TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Gable Tool Dia, of Well -Excavation C <br /> Domestic k <br /> /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 /> i Geophysical � Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: State Work Bone <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 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 Heilth District .a <br /> WELL DRILLERS REPORT of the well and notify them before putting. the. well in use. The above <br /> information i ue to the best of my knowledge and belief. I WILL CALL_FOR A GROUT, INSPECTION <br /> PRIOR TO GRO ING AND A FINAL IN ECTIO . <br /> SIGNED I TITLE <br /> OT PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: I/V 100V <br /> PHASE II E ION PHASE III/FINAL INSPECTION <br /> f INSPECTION BY ATE INSPECTION BY DATE /0 - 3 - T;7 <br /> 2m <br /> E H 1426 r Rev. , 1-74 b��I7 _ <br />