Laserfiche WebLink
. 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE: 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 ADDRESSVIM,, fL CENSUS TRACT <br /> Owner's Name i <br /> Phone <br /> Address City <br /> Contractor's Name l / <br /> License Phone •- �f a <br /> TYPE OF WORK (Check): NEW WELL DEEP /? RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION k-' PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other j J <br /> DISTANCE TO NEAREST: SEPTIC TANKS— SEWER LINES- PIT PRIVY �^ <br /> SEWAGE DISPOSAL FIELD — GES"GM/SEEPAGE PIT ��4-OTHER ---- <br /> PROPERTY LINE - PRIVATE DOMESTIC WELVK!40—f`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: ContractorA1A A ,S <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: /7 State Work Done <br /> ES•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 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 INSPECTIO <br /> STGNED <br /> PTAVt P ON .REVERSE SID _ <br /> FOR DEP TMENT USE ONLY <br /> PHASE I <br /> a <br /> APPLICATION ACCEPTED 'BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II OUT INSPECTIONPHA III/F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -- <br /> '• ,E H 1426 Rev. 1-74 1_74 2M <br />