Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATFON CENSUS TRACT <br /> Owner's Name _ Phone <br /> Address � � ) City <br /> Contractor's Name , 0.-•._.•.� • <br /> License # �6� Phone �7 <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN -/-7 RECONDITION /7 DESTRUCTION _� <br /> PUMP INSTALLATION �( PUMP REPAIR /-7—PUMP REPLACEMENT-17 <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 o� <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 Q <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP 'INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ;REPAIR: L7 State Work Done <br /> ES;TRUCTION 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 CA16L FOR A GROUT INSPECTION <br /> PRIOR- TO GROUTING AN AL INSP N. <br /> SIGNED TITLE - <br /> �__ (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS-.* <br /> i <br /> PHASE ,II GROUT INSPECTION P Sj FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY V DATE <br />� ' E H 1426 Rev. 1-74 1-74 2M <br />