Laserfiche WebLink
. <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a <br /> THIS'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued��7 <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 CENSUS TRACT <br /> Owner's Name Phone <br /> n�� <br /> 1 <br /> Address / City ) <br /> 1 <br /> Contractor's Name A I e License # f Phone <br /> TYPE OF WORK (Check) NEW WELL '/'-'/, DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT ' <br /> Other ,/ -/ <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 ToolDia. of Well Excavation <br /> .Domestic/private f Drilled Dia. of Well Casing <br /> Domestic/public I Driven P Gauge of Casing v <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal. 1 Other Other Information �. <br /> Geophysical Surf ace Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type ofPump H.P. ; <br /> t 1 <br /> PUMP REPLACEMENT: / ' State Work Done p <br /> PUMP-REPAIR:. /- / State Work Done, <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 1 <br /> Describe Material and Procedure <br /> ` ' <br /> I hereby agree to comply withJall 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 oA a new well, I will furnish the San Joaquin Local Health District a <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 FINALIINSPECTION. <br /> SIGNED .,.n..�_.,� .- 46? <br /> ,F.Apy TITLE <br /> i, <br /> (DRAW PLOTPLAN ON REVERSE SIDE) ^� <br /> ' FOR )DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY a n' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> k INSPECTION BY DATE INSPECTION BY ,,�' DATE -�a <br /> E H 1426 Rev. 1-74 <br />