Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 y� <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. 1.862 and the Rules and egu ations of the SanJo n Local Health District. <br /> JOB ADDRESS/LOCATION ' CENSUS TRACT ' <br /> Owner's Name Phone <br /> f' <br /> Address City <br /> Contractor's e �� icense � �� Phone <br /> f <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 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 r Surface SeaINInstalled B <br /> PUMP INSTALLATION. <br /> Contractor <br />' .� Type of Pump H.P• <br /> w PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Appro-ximate 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 /> I after completion of my work on a new well., I will furnish the San Joaquin Local Health District a <br /> E 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 GRO TING AN A INAL INSPECT ON. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDla} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I { <br /> APPLICATION ACCEPTED BY L!V DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ' G© DATE -72 <br /> o!7.7 _ 2M <br /> ► E H 1426 Rev. - I-74 - <br />