Laserfiche WebLink
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. <br /> THIS PERMIT EXPIRES 1I1�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 workl�herein described. This'Iapplication 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 f4 '" ' C.[/f L�" / IMI N - � CENSUS TRACT <br /> Owner's Name Phone A3/ <br /> 70 <br /> Address Ci <br /> g)g4'79� <br /> Contractor's Nam License ��'3�3 Fhon <br /> i` <br />`TYPE'OF`WORK (Check) :' LL NEW"WELI;'--/ / ` DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / MI'MP REPAIR / / PUMP REPLACEMENT <br /> . other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 11� 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 DrivenGauge of-Casing QUI <br /> Irrigation Gravel Pack r Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout l 111 <br /> Disposal 1 Other Othe`r .Information <br /> -Geophysical <br /> Surface 5eal' Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ' Ali 4 <br /> PUMP REPLACEMENT: /,, / State Work <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 �F <br /> and the State of California pertaining to or regulating well ''constructi.on. Within FIFTEEN DAYS r <br /> after completion of my work on 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 ]FINAL INSPECTION. <br /> SIGNED jl �, TITLE <br /> } (DRAW PLOTIPLAN ON REVERSE SIDE <br /> 4 FOR DEPARTMENT USE ONLY <br /> PHASE I ! -� - <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY a DATE <br /> 1.x(7.7 ", P1! <br />