Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOL OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. xR . <br /> Telephone : (209) 466-6781 y <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'. 1$62 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION `- CENSUS TRACTJF <br /> i <br /> t ' I <br /> Owner's Name 7� Phone i <br /> Address o <br /> City <br /> Contractor's Name ' j <br /> License # :�La/_,C�:Phone <br /> s <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN /_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTLATION REPAIR/ / PUMP REPLACEMENT /� <br /> AL <br /> Other <br /> DISTANCE. TO NEAREST: SEPTIC TANK _ SEWER LINES <br /> (j PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER f <br /> PROPERTY LIME ,-- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation a <br />_i/Domestic/private __=_1--Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing c- <br /> j <br /> Irrigation Gravel Pack Depth of Grout Seal j <br /> Cathodic Protection. Rotary Type of Grout <br /> Disposal Other Other Information <br /> a <br /> Geophysical- °-°-- - - Surface Seal Inst-alled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump tt H.P. <br /> . . I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done -- <br />)ESjRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an rocedure <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 /> TELL DRILLERS REPORT of the well and notify them before putting the wellin use. The above i <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROU ING AND A FIN4L INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> ' <br /> FOR DEPARTMENT USE ONLY ?-/I <br /> S78 <br /> PHASE I <br /> PLICATION ACCEPTED BY Z( DATE <br /> kDDITIONAL COMMENTS: <br /> . PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 •uA.r" I_7G <br />