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. �JO <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a 7 <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 ADDRESS/LOCATION ILS CENSUS TRACT <br /> Owner's Name �Q / !4�, <br /> Phone ��- <br /> Address j 719 <br /> �f 4 <br /> City �}N 7 c{9 <br /> Contractor's Name / d~ License #S!5_4c�Phone <br /> TYPE OF WORK (Check) : 'NEW'`WELLT <br /> DEEPEN`/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMPINSTALLATION PUMP REPAIR / I PUMP REPLACEMENT <br /> Other <br /> DISTANCE TONST: SEPTIC TAVK SEWER L ES PIT PRIVY <br /> SEWAGE DIS 'SAL FIELD CESSPOOL/S�E,PAGE .PI V. OTHER <br /> PROPERTY LI ,PRIVATE DOMES C WELL PUBLIC OMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable 'Pool Dia, of Well Excavation <br /> Domestic/private Drilled ' <br /> ` � � Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigatio 3 Gravel Pack-` Depth of Grout Seal- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical a Surface Seal Installed- By: <br /> PUMP INSTALLATION: Contractor Y <br /> _ .-TYPe-of Pimp SOA <br /> _ H.P. 3 <br /> PUMP REPLACEMENT: / State Work Done f ul` <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 of my knowledge and. belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. {' <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT 'PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASA III/F NAL INSPECTION - <br /> INSPECTION BY DATE INSPECTION BY DATE � . <br /> E H 1426 Rev. 1-74 AAk 1177 _ w <br />