Laserfiche WebLink
Q1� vA JOAQUIN LOCAL HEALTH DISTRICT <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. (�� <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 t C e 6 A If? /P6rf T WAY CENSUS TRACT <br /> Owner's Name sT WA 7-1: 07S77 Phone <br /> 2 <br /> Address 2526 F LIE,09tMT37 �7 _ dC4-7_,W1 <br /> Contractor's Name Cl Ar",e G fl/ K f4 0J P 60' License U 7GG/l�2_ Phone'yid--SJW . <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /_/ RECONDITION / / • DESTRUCTION /-7PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT /� <br /> AL <br /> Other- E/ <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 Cable Tool Dia. of Well Excavation to <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 X Rotary Type of Grout A. <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO, D ,FIN . INSPECTION. <br /> SIGNED TITLE ( yr <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIIFINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1177 2M <br />