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 /> s <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued/ <br /> (Complete In Triplicate) <br /> Application is $ereby 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 Ru s and Regulations of the San Joaquin Local Health District. <br /> golf <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name <br /> Address <br /> Ci <br /> Contractor's Name License 46:-_'�7_jhone��� <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN -/—/ RECONDITION /_7 DESTRUCTION f <br /> PUMP INSTALLATION / J PUMP REPAIR f_/­PUMP REPLACEMENT <br /> Other /_7 <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 <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work <br /> PUMP .REPAIR: /7—State-Work Donees <br /> TRUCTION 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 bistricit <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 4 <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED le,,�- TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,� l" <br /> APPLICATION ACCEPTED BY DA E V), <br /> ADDITIONAL COMMENTS: _2 e 4jP.0 'n� d.��D s67� �:•. K41 <br /> PHASE II GROUT INSPECTION PH SE III/FINAL INSPECTION <br /> INSPECTION BY DATE NSPECTION DATE <br /> � <br /> /,(f QM �- oz "^ <br /> A <br /> E H 1426 Rev. 1-74 w 5X ;, "" ��f : 1177 <br />