Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR�OFMCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. d <br /> & ` �+ Telephone: (209) ' 466-6781 610_ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued b z <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.42 I <br /> JOB ADDRESS/LOCATIONk� CENSUS TRACT _ <br /> r Ownerls Name Phone <br /> Address City <br /> Contractor's Name ~ "---L-icens.e, # Phone <br /> TYPE OF.WORK (Check) : NEW WELL /DEEPEN I RECONDITION DESTRUCTION <br /> DESTRUCTION <br /> ` PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT=M-— <br /> Other <br /> 'DISTANCE TO NEAREST: SEPTIC TANK IA6F--SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE PI��QOTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ,M PUBLIC DOMESTIC WELL <br /> e INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ' Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> 49 <br /> Domestic/public Driven Gauge of Casing /10 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> ' Cathodic Protection _ Rotary Type of Grout _ c p <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: .� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H'-X <br /> PUMP REPLACEMENT: /, / S tate-Work Done <br /> PUMP -.REPAIR: / / State Work Done <br /> ' DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Descrfbe' Material and Procedure <br /> fI hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> land the State of California pertaining to or regulating well construction., Within FIFTEEN DAYS <br /> tafter 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-we-I-1.in-•u-se•.—The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G5QUTJNG__AM FI AL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> , APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> P SE II GROUT INSPECTION PHASE III/FINAL INSPECT N <br /> INSPECTION BY DATE {�- I(� ]n} , INSPECTION BY L �ODATE <br /> -7 kA.\\ 'z% <br /> 1177 2M <br /> s E H 1426 Rev. 1-74 �_, _ <br />