Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR, OFFICE USE: Of 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> 1 1 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedl�a <br /> h (Complete In Triplicate) <br /> Application is Aereby made to'Ithe 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 arid,the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - 1 ,S CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address City <br /> Contractor's Name 1 License 11-lflra4 Phone d <br /> a . i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN J / RECONDITION / / DESTRUCTION /_ <br /> PUMP INS ALLATI / / PUMP REPAIR / / PUMP REPLACEMENT, /-7 <br /> 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 <br /> : INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private t Drilled Dia. of Well Casing <br /> Domestic/public y� [ Driven Gauge of Casing _ - Q <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal r Other r Other Information V <br /> Geophysical. ," Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contrafor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> E PUMP .REPAIR: / / State Work Done <br /> DESTTR-U,CTION--OF-WELL:----Well Diame-t-er-- Approximate Depth <br /> ® Describe Material and Procedure <br /> .._. __ <br /> I hereby agre 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 <br /> tWELL 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 TOG UTING PN4FINAL INSPECTION. `-^' <br /> ESIGNED TITLE <br /> (-Q-, , <br /> F I (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 <br /># ADDITIONAL COMMENTS: I F <br /> PHASE II GROUT INSPECTION PHASE I /FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY;E DATE ZO 2 S 7 <br /> f • <br /> I IZ7 <br /> E H 1426 Rev. 1-74 <br /> c=.. <br />