Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> �0& OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif . ��� <br /> Telephone: (209) 466-6781 �G <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �a k <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 Jop.quin <br /> County Ordinance No. 1862 and the Rules and Regul ons of�the <br /> J San Joaquin Local Health District. F <br /> JOB ADDRESS/LOC TION �d ! i ` CENSUS TRACT <br /> 577 <br /> Phone t <br /> Owner's Named <br /> Address <br /> Contractor's Name <br /> License # �� Phone194, <br /> . i <br /> TYPE OF .WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION / -/ PUMP ,REPAIR PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ,. CONSTRUCTION SPECIFICATIONS pu) <br /> Industrial Cable Tbol Dia. of Well Excavation <br /> Domestic/private Drilled Dia.. .of Well. Casing <br /> Domestic/public Driven Gauge of Casing <br />` <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> g ., <br /> 4 Cathodic Protection Rotary Type -of Grout <br /> Disposal. Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> C TYPE of Pump H.P. <br /> iPUMP REPLACEMENT / / State Work Done <br /> PUMP °.REPAIR: �/ State Work Don ^� � <br /> iDESiRUCTION OF WELL,: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> II 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 GROUTING AND A FINAL INSPECTION. p <br /> ' SIGNED TITLE �n� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I - <br /> .177 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I ROUT INSPECTION PHASE III FINAL INSPECTION <br /> ' INSPECTION BY DATE INSPECTION BY DATE /� <br /> 1177 SPI <br />