Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. IC <br /> Telephone: (209) 466-6781. �7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7/ -17.317 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued SEC22 � j <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION — �Q � <br /> CENSUS TRACT <br /> Owner's Name <br /> ' Phone <br /> Address City <br /> Contractor's Name d' License Phone r <br /> i <br /> TYPE OF WORK (Check) ; NEW WELL DEEPEN/ / RECONDITION f_1 DESTRUCTION /_7 <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK Q SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSALFIELD CESSPOOL/SEE�GE PIT'� OTHER <br /> PROPERTY LINE/'PRIVATE DOMESTIC WEL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q. <br /> Industrial Cable Tool Dia. of Well Excavation /i <br /> 7C Domestic/private Drilled Dia. of Well Casing y <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal tJ <br /> Cathodic Protection Rotary Type of Grout f� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT J / State Work Done <br /> PUMP -REPAIR: / / State Work Done <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 /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my wo on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPOR the well and notify them before putting the -well in use. The above <br /> information is tr to of knowledge and belief. I WILL C L FOR A GROUT INSPECTION <br /> PRIOR TO FINAL I IO <br /> SIGNED TIT <br /> DRAW PL T PLAN ON REVERSE S <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I -•-1 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS:, :rA N G •r r <br /> PHASE I MOUT SPECTIQNPHA I / INAL- I SPECTIO <br /> INSPECTION BY DATE ,Z 34 7 7 `" "INSPECTION BYDATE z <br /> E H 1426 Rev. 1-74 . <br /> 3/76 2M <br />