Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Q4490Q Av CENSUS TRACT <br /> Owner's Name Phone <br /> Address w �j/ City l <br /> Contractor's Name S ,ti/ License #,:2 <br /> Phone � 7 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_% RECONDITION CIT DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE O NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p , <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool. Dia. of Well Excavation �1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation I.. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> —Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor -" <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done E ,e, , ALL <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br />�-�-�- 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO G: UTING AND IFI], <br /> AL INSPECTION. <br /> SIGNED TITLE _ <br /> D W PL T PLAN ON REVERSE SIDE) <br /> F EPART T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT �/�L./N,07—/ DATE _'7 A�` 7,6/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRksivVil/ 'IN INSPECTWN <br /> INSPECTION BY DATE INSPECTION BY / DATE ,J <br /> E H 1426 Rev. 1-74 3/76 2M <br />