Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: fj 160" '. Hazelton Ave. , Stockton, Cal <br /> 'Telephone: (209) 466-6781 ..W <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Sg/kJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedZZ <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ime �� 5 1c.1.E r` f CENSUS TRACT <br /> Owner's Name _ Phone <br /> Address s�City � f <br /> Contractor's Name �•j` ,` �g /g ,L License # 3Phone 221131 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/_% RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTAILATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <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 p <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �V <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 Surface Seal Installe B : r-- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <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 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 GR FOR A T INS ECTION <br /> PRIOR TO GRO T G AND A_74 <br /> FINAL PECTION. <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVVRSE SIDF13 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � �cx �—L� DATE <br /> ADDITIONAL COMMENTS: _ 117 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 214 <br />