Laserfiche WebLink
�/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> , <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22 2 - jam ' <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued P-� t <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 Joagpin4 <br /> County Ordinance No. 1862 and 'the Rules and Regulations of the San Joaquin Local Health District. Y <br /> f <br /> JOB ADDRESS/LOCATION ocan inl _f CENSUS TRACT <br /> 0 <br /> Owner's Name Phone f <br /> Address City <br /> Contractor's Name License ,Phone <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /% RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ 7PUMP REPAIR / / PUMP REPLACEMENT JV .�. <br /> Other LY <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 I Cable Tool Dia, of Well Excavation .. <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing - <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary,_ _ - „Type of .Gxout _ <br /> Disposal Other Other Information ; <br /> Geophysical Surface Seal Installed By: c <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> r - <br /> PUMP REPLACEMENT: State WorkDone <br /> r <br /> PUMP .REPAIR: State Work Done . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure F <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 TI G AND A FINAL NSPECTI <br /> SIGNEDTITLEG'�zG�, <br /> q DRAW PLOT PLAN ON REVERSE SIDE) , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I3!�— <br /> APPLICATION ACCEPTED BY �✓ BATE 72 <br /> ADDITIONAL COMMENTS: ! - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE AZ INSPECTION BY ) DATE 9 <br /> -.. E H 1426 Rev. 1-74 : 1177 ' 2M <br />