Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FQSiOFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ- <br /> THIS <br /> -THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br />. <br /> Application (Complete In Triplicate) <br /> A <br /> pp on 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 Eade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and. Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION - �- <br /> f CENSUS TRACT <br /> Owner's Name 1 (� Phone <br /> Address 3 ' <br /> City <br /> Contractor's Name <br /> License # 4f e 1—Phone��s <br /> TYPE OF WORK (Check) : NEW WELL '/? DEEPEN '/? RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATIONPUMP REPAIR /� PUMP REPLACEMENT <br /> other L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOME5TIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> IndustrialCONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private DrilledDomestic/ Dia. of Well Casing �. <br /> Irrigation <br /> 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 Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> . Type of Pump H.P. _LL ? <br /> PUMP. REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: /? State Work Done <br /> ES;TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 /> PRIOR TO GROUT <br /> SIGNER G AND A FIN INSPECTION. <br /> ' <br /> TITLE <br /> �(DRA�WPMT PLAN ON REVERSE SID <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APP LIGATION ACCEPTED BY L11Z DATE -- 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIl INAL INSPECTION <br /> INSPECTION,,BY DATE <br /> INSPECTION BY <br /> DATE _2 <br /> -E H 1426 Rev. 1--74 <br />