Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE.OFFTCE USE: 1601. E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209)' 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permirt No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby 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 Jpaguin <br /> County Ordinance No. 1862 and the Rules Regulations o7fthe San J quip Local Health District. <br /> 7 JOB ADDRESS/LOCATION S TRACE <br /> Owner's Name ��� �f PhonlFfZ'7� I <br /> City C�-VA' 0A <br /> Contractor's Name License /PaS�'3 Phone4Ld4g./'7�"" <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN -/-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / REP EMENT /7 <br /> Other / / L <br /> DISTANCE TO NEAREST: SEPTIC T 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 <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 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 <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 3oaquin 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 GROUTING AND A FINAL INSPECTION, <br /> SIGNED TITLE �otto <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ (� DATE F D <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE lkiiii7FINAL INSPFC 10N <br /> INSPECTION BY DATE INSPECTION BX DATE <br /> E H 1426 Rev. 1-74 ' 1/77 �02M <br />