Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> "FQfi OFFICE USE: 1601 E. Hazelto ,- Ave. , Stockton, Calif. G} <br /> Telephone: _{209) 466-.6781 <br />�t APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � �, <br /> i THIS PERMIT EXPIRES 1 YEAR FROM-DATE ,ISSUED 1 Date TO'sued: ` -at - d <br /> .(Complete In Triplicate) .; ,,, t. <br /> - Application is' hereby made'`Co the San Joaquin Local Health Disttict•:..for� a •peridit. to coft tract <br /> and/or install the work herein described.- "This application is —made—.4n. compliatice-44ith Sen'J6a4uisn <br /> County•,Ordinance No. 1862 'uiid the Rules and Regulations of the San::.�negtsir�=Local Health Die"tri'et. <br /> JOB ADDRESS/LOCATION <br /> p p �:CENSUS fiRACT ' <br /> i.-Owner's Name .�� N Phone �'� <br /> Address. <br /> Contractor's Name License- # '' Phone. <br /> f TYPE OF WORK {Check) : NEW WELLDE9PEN -/7 RECONDITION /7 DESTRUCTION.-/7 - + <br /> PUMP INSTAL TION / I PUMP REPAIR PUMP REPLACEMENT. /7 <br /> Other /—/, 7-% — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY s <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' PROPERTY LINE -- PRIVATE DOMESTIC WELL.' -- • PUBLIC- DOMESTIC WELL <br /> f INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS3 <br /> Industrial . }_ Cable Tool - Dia. of Well Excavation C,` <br /> } Domestic/private Drilled Dia. of Well Casing C, <br /> Domestic/public Driven' <. ' 'Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout- Seal <br /> Cathodic Protection Rotary - a Type of Grouts <br /> I Disposal Other t Other Information <br /> Geophysical. u :R °'.Surface -Seal Installed Bj: <br /> VPUMP INSTALLATION: Contractor' <br /> Type .of Pump- H.P. <br /> PUMP REPLACEMENT: , / / State Work bone <br /> ` PUMP .REPAIR: / / State Work Doris <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 /> land the State of California pertaining to or regulating well"•construction. Within .FIFTEEN DAYS <br /> after completion of my work on anew well, I will furnish the San Joaquin. Local Health .District` a <br /> : WELL,DRIL ERS. REPORT of the well'aud notify them before putting..the.-well. in-.use..'-. .The above s <br /> info tion is true to t -best.6my..knowle3ge and belief. I WILL CALL XNSkCTION, <br /> PRIOR GR UTING AND I -ION. <br /> SIGNED - { TITLE •~ <br /> (DRAW PLOT PLAN ON REVERSE- S.IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � p " <br /> APPLICATION ACCEPTED BYAz <br /> Gr DATE '` <br /> ADDITIONAL COMMENTS: - <br /> PHASE II ROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY, DATE: .j 6 <br /> E,H"1426" Rev. 1-74 <br />