Laserfiche WebLink
t SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> FO&rOFF'ICE USE: 1601 E. Hazelton Ave', Stockton, Calif. <br /> Telephone: -(209) '466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES .l I YMA FROM`DATE ISSUED Date Issued �-J-(- <br /> (Complete-In Triplicate) <br /> J-(-(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 2 . 6F)e MOW CENSUS TRACT <br /> owner's Name Phone <br /> Addres's City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN /? RECONDITION /—T DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR. /_7 PUMP REPLACEMENT <br /> Other Rr U f <br /> ve <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 1WELf <br /> INTENDED USE ---TYPE-OF-WELL.__.__ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavatiioa - Mw <br /> . Domestic/private Drilled .u. ► +Dia. of Casing V' <br /> Domestic/public --------Driven_ �_,,,_ Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grogt-TSeal" ---`7.".- 1f <br /> Cathodic Protection Rotary Type of Grout +.f_ <br /> Disposal Other Other Information , <br /> Geophysical } Surface Seal%'Iristalled By: 6kzl4yev f : ' <br /> PUMP INSTALLATION: Contractor �t1-„Y,�s,� <br /> Type of Pump s P. ' <br /> PUMP REPLACEMENT: / / State Work Done � <br /> PUMP '.REPAIR: /-']r State Work Done � - <br /> t <br /> PE&TRUCTION OF WELL: Well Diameter � `. Approximate Depth <br /> Describe Material and Procedure &22 <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 /> informatio is true to he-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TIG AUD A VINAJ4INSPECTION. ji, <br /> SIGNED Y TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION - -- - P NAL INSPECTION W <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> w� E H 1426 Rev. 1-74 1-74 2M <br />