Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. g� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2_Zo�- <br /> 29 <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 /> jkN3'NADDRELOCATIO CENSUS TRACT <br /> Cwnervs NamePhone <br /> Address �p �j � City (yyc <br /> Contractor's Name t �� License # <br /> 2J,11Phone lam' <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN / / RECONDITION /_/ DESTRUCTION 1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT f? <br /> Other / / G, <br /> DISTANCE TO NEAREST: SEPTIC TANK ?Q4 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 149__t- 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 J <br /> _ '�pC Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing _ PUC. 11 0 <br /> Irrigation ')e- Gravel Pack Depth of Grout Seal Ro 4=_ <br /> Cathodic Protection 'A, Rotary Type of Grout &4 '1 414 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 f my-knowledge and belief. I WILL CALL FOR A GR UT INSPECTION <br /> PRIOR TO G G ANDoA FIN SPECTION. <br /> SIGNED TITLE <br /> !�(DRAWPLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE l� 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE �2— :Z_ INSPECTION BY DATE ? Gj <br /> E H 1426 Rev. 1-74 � 3/76., <br />