Laserfiche WebLink
SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE 1601 E. Hazelton Ave., ,Stockton, Calif. <br /> Telephone: (209) 466-6781 r,� ? <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. r}�/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedT�O <br /> (Complete In Triplicate) <br /> Application isiereby made to the San Joaquin Local Health District for <br /> q 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 Miles and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name)��,OnL },, ! �,-Z-I � <br /> Address ' C1tys=�1c•.� <br /> Contractor's NameC"7"Z 1-`7 License <br /> r <br /> TYPE OF WORK (Check): NEW WELL F7 DEEPEN /= RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANS 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 SPECIFICATIRIS <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'"-'- <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. . <br /> PUMP State Work Done <br /> PUMP °.REPAIR: / State Work <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 DistriRF <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 e t- TITLED <br /> (DRAW PLOT PLAN ON REVERSE SID ' <br /> /FOR DEPARTMENT USE ONLY <br /> PHASE I !� n -:-- <br /> APPLICATION ACCEPTED BY n DATEr ' ' <br /> ADDITIONAL COMNKNTS; <br /> PHASE II GROUT INSPECTION P 1I AL IN <br /> INSPECTION BY DATE INSPECTION BY TE t- <br /> E H 1426 Rev. 1-74 ^ 1177 " 2M <br />