Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 2_// <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 Distract. <br /> JOB ADDRESS/LOCATION f <br /> CENSUS TRACT � <br /> s <br /> Owner's Name <br /> Phone '. <br /> Address �`% <br /> Cityis <br /> Contractor's Name License U�Phone -c,! <br /> t <br /> TYPE OF WORK (Check) : NEW WELL/% DEEPEN /_/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION J / PUMP REPAIR /—/ PUMP REPLACEMENT <br /> Other / J <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 rN <br /> Irrigation Gravel Pack Depth of Grout Seal (� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other <br /> Geophysical Other Information <br /> ' u <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor �� <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: State Work DoneIle <br /> >- , <br /> PUMP ,.REPAIR: / / State Work Done 1 <br /> DESTRUCTION OF WELL: Well -Diameter' .�r � - - ' ; - --- � - <br /> Approximate I7ept� <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 />'RIOR TO GR UTING AND A FINAL IN PECTIO . <br /> SIGNETS TITLE <br /> (D W PLOT PLAN ON REVERSE SID-E) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIJFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY GAJ DATE f -f- 7 <br /> E h 1426 Rev. 1-74 1177 - 2M <br />