Laserfiche WebLink
:Qn�/' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF,;OF CE USE. f / ,1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -,2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /,1.2- <br /> (Complete, In Triplicate) <br /> Application is hereby made to the San Joaquin Focal Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOS ADDRESS/LOCATION 3 7 C4 CENSUS TRACT <br /> Owner's Name �J c ¢� Phone <br /> Address City <br /> Contractor's Name License # / 3 y Phone <br /> TYPE OF WORK (Check): NEW WELL. DEEPEN '/ 7 RECONDITION I? DESTRUCTION f_7 <br /> PUMP _ <br /> �INSTALLATION /7 PUMP REPAIR 7 PUMP REPLACEMENT .� <br /> F 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 G <br /> ' INTENDED. USE ;TYPE OF WELL - .. -CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation U <br /> Domestic/private Drilled Dia. of Well Casing U <br /> j 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 f <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: State Work Done c <br /> IV <br /> 4 PUMP :REPAIR: / / :State Work Done <br /> DESTRUCTION OF WELL: WelliDiameter 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 /> i 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 therm before putting.. the..well in.use... .The above <br /> information is true to the•best of m .. wl a elief. I WILL CALL FOR A GROUT INSPECTION <br /> ' PRIOR'TO TING AN A FINAL INSP . <br /> SIGNED <br /> f RAW LO ON REMSE SIDE <br /> t OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION BY ACCEPTED ` / DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT:INSPECTION _ SE III FINAL INSPECTION- <br /> ; INSPECTION BY ;DATE INSPECTION BY DATE A< <br /> ' E H 1426 gear. 1-71: h/75 2M <br />