Laserfiche WebLink
Cw .. SAN 30AQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: L11--1 <br /> / 1601 E. Hazelton Ave. , Stockton, Calif. 5 <br /> L11 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7f <br /> ! (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health <br /> istrict made forca p permit <br /> to construct San Joaquin ' <br /> and/or install the work herein described. This application <br /> and Regulations of the San Joaquin Local Health District. <br /> County Ordinance No. 1862 and the Rules <br /> �{ CENSUS'TRACT <br /> JOB ADDRESS/LOCATION I® <br /> .Owner s .Name <br /> S y Phone <br /> j �O "7z �(/ City Ac/ <br /> Address � <br /> ' <br /> License # aw Phone <br /> Contractors Name <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /-7 DESTRUCT' — <br /> PUMP INSTALLATION I / PUMP REPAIR/_/ PUMREP <br /> LACEME <br /> Other, /_7 / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -SPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE " PRIVATE�DOMES I_ WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE iTYPE OF WELL CONSTRUCTION SPECIFICATIONS o <br /> Industrial . t Cable Too-1� Dia. of Well Excavation <br /> Domestic/private Drilled {Dia. of Well Casing <br /> r <br /> Domestic/public Driven Gauge ofrCasing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic protection Rdtary Type of Grout <br /> Disposal Other _ Other Information- <br /> Geophysical * " Surface Seal Installed B <br /> .. <br /> PUMP INSTALLATION: Contractor. ` <br /> H.P. <br /> Type of Pump <br /> r. <br /> PUMP REPLACEMENT: S tate'-Work-Done <br /> ""` <br /> PUMP ,REPAIR: / / State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: `-� Well Diameter R <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 /> well, I will furnish the <br /> after completion of my work on a new San Joaquin Local Health District r <br /> WELL DRILLERS REPORT of the well and notify them before putting the. we111 in use. The above <br /> information is true to the best of my knowledge and belief. I WILL ;CAL <br /> FOR A GROUT INSPECTI N <br /> PRIOR TO GR UTING AND FI AL INSPECTION. TITLE <br /> SIGNED � i. <br /> p W. PLbT' PLAN ON REVERSE SIRE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY r <br /> ADDITIONAL COMMENTS: p I/ INAL INSPECTI N <br /> PHASE II GROUT I PECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> i 3/76 2M <br /> E H 1426 Rev. 1-74 <br />