Laserfiche WebLink
vSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: <br /> lil 601 E. Hazelton Ave. , Stockton, Calif. . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, jr C(!J <br /> THIS PERMIT EXPIRES1 YEAR FROM DATE ISSUED Date Issued / _7y <br /> (Complete In Triplicate) <br /> pplication 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 Joaquil <br /> County Ordinance No. 1862 annd/the Rules and Regulations of the San Joaquin Local Health District. <br /> .:OB ADDRESS/LOCATION C � � � �Lf'C'/� �/ t -/—CENSUS TRACT <br /> caners Name horse <br /> Address /� D //` / fs�,� _ <br /> City e",, 'i �r <br /> ontractor's Name ���'> �''f6�"f f .I / y(7License Phone — <br /> YPE OF WORK (Check) : NEW WELL / / DEEPEN /_% RECONDITION DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION /—/ PUMP REPAIR / PUMP EPLACEMENT /-7 <br /> Other / J 14-ie — <br /> ISTANCE 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 C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 Installed By: <br /> _-W INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> D'W REPLACEMENT: / / State Work Done <br /> JMP .REPAIR: / J State Work Done <br /> :S-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> id 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 /> DELL DRILLERS REPOR�f -the well and notify them before putting the well in use. The above <br /> iformation is tru& to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 1.-,IOR TO GROUTI V_.AND,Y„(,,_F•I-NAi -INS.PECTION'. <br /> SIGNED <br /> .. TITLE <br /> �€ (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 'PLICATION ACCEPTED BY DATE <br /> )DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FIN SPECTION _ <br /> T ;SPECTION BY DATE INSPECTION BY .,�-e DATE -� 7S <br /> E H 1426 Rev. 1-74 <br />