Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH, DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �r � � 4 <br /> Telephone: (209) 466-6781 I 1 <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 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 2 4/5- 7 _ � CENSUS I TRACT <br /> Owner's Name <br /> I Phone <br /> �J� <br /> Address City <br /> �� <br /> Contractor Name <br /> ' ��a�., �/T.� License # Phone <br /> s _ — <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION ,/�/ DESTRUCTION /� <br /> PUMP INSTALLAT N / / PUMP REPAIRPUMP REPLACEMENT /_7 <br /> Other <br /> DISTAN TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY `f <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ 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 <br /> i <br /> Drilled Dia. of Well Casing <br /> Q <br />' Domestic/private � <br /> Domestic/public - Driven,—,i, �`- <br /> �` Gauge of Casing <br /> Irrigation Graver 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: / / State Work Done <br /> PUMP .REPAIR: State Work Done W4 AIV4 <br /> If DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure rx ''. <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- 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 GROU G A4D,A ZIIESCTION. / / <br /> ' SIGNED TITLE <br /> DRAW <br /> PLOT PLAN ON RE ER DE) <br /> FOR DEP TMENT-USE-ONLY <br /> PHASE I DATE /Z <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> -PHASE 'II GROUT. INSPECTION : :'�,,j <br /> ` P S /FI INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> (R76 2M <br /> R H 1426 Rev. 1-74 <br />