Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DI <br /> STRICT <br /> FOE{OFFICE USE: <br /> 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 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 �® 9go <br /> CENSUS TRACT <br /> Owner's Name erg Phone <br /> Address <br /> City qf,+ <br /> Contractor's Name 4 e, ��. <br /> License #? 75►f Phone <br /> 46 <br /> TYPE OF WORK (Check): NEW WELL/?� DEEPEN /? RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION � PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /% --- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <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 , W <br /> Domestic/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 Grout3 - <br /> Disposal Other Other Information a� <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / IT State Work Done <br /> . . r <br /> PIN .REPAIR: /-7 State Work Done <br /> E&TRUCTION 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 Health District a <br /> WELL DRILLERS REPO of the well and notify them before putting the- well in use.. The above <br /> information is t e to the best of my . nowledge and belief. I WILL CALL-FOR.A GROUT INSPECTION <br /> PRIOR TO GRO I S N. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: vr� !* y <br /> PHASE II GROUT INSPECTION f PHASE III FINAL INSPECTION <br /> � / <br /> INSPECTION BY r. DATE , INSPECTION BY DATE a/42$/75 <br /> 1 E H 1426 Rev. 1-74 1-74 2M' <br />