Laserfiche WebLink
FOR OFFICE USE• B SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> (� . 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. =� <br /> a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> '. Date Issued? � 7 � <br /> (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District fqr a permit to construct <br /> and/or install the work herein described. This application is made_ in compliance with San Joaquin ? <br /> Gou t Ordinance No. 1862 and` the Rules and Regulations of the San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATION, <br /> • CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address -2- <br /> City <br /> Contractor's Name I�'3 �� y <br /> License � Phon <br /> TYPE OF WORK (Check): NEW WELL RECONDITIONDESTR—PUMP <br /> / UCTION /7 <br /> AL <br /> PUMP INSTLATION / REPAIR /—/ PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAN 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 \� <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> mestic/private Drilled Dia. of Well Casin <br /> V <br />.�� Domestic/publig <br /> Irrigation c Driven Gauge of Casing it <br /> Gravel Pack Depth of Grout Seal 1 <br /> Cathodic Protection —�tary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br />'UMP REPLACEMENT: / / State Work Done ry <br />'UMPl.UPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the-well in use. The above <br /> nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 3IOR TO GROUTING AND_&FINAL INSPECTION. <br /> IGNED <br /> TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE •— <br /> iASE T FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY <br />)DITIONAL COMMENTS; DATE <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> JSPECTION BY DATE INSPECTION BY ZW DATE 1A-, .; -7 7' <br /> E H 1426 Rev. 1-74 1 . 77 " onr <br />