Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. , .Stocicron, Calif. <br /> Telephone: (209) 466-6781 <br /> ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES. I. YEAR FROM DATE ,ISSUED Date Issued <br /> (Complete .In Triplicate) TT� <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. he :Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDPEb57ZOCATI6N i4-CCT4 <br /> y Phone 3 r_ L <br /> owner's Name. <br /> City a-<_a <br /> Address / <br /> �, _ License #l(0 7 Phoned � - <br /> Contractor's Name _ <br /> ' TYPE OF WORK (Check) : NEW WELL ,/—/ DEEPEN /� RECONDITION /_� DESTRUCTION / <br /> PUMP INSTLATION PUMP REPAIR � PUMP REPLACEMENT IST <br /> AL <br /> Other <br /> sr- <br /> DISTANCE TO NEAREST: SEPTIC TALK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL-.FIELD,„ - _. _CESSPOOL/SEtPAGE PIT OTHER r <br /> CONSTRUCT <br /> INTENDED USE TYPE OF WELL ION SPECIFICATIONS +• <br /> Industrial Cable Tool Dia. of Well\Excavation I <br /> Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing.. <br /> 3 Irrigation Gravel Pack Depth of Grout Seal <br /> Other <br /> Rotary •Type of Grout I \• '4 <br /> Other - Other Information <br /> NP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> { <br /> 3�l <br /> PUMP REPLACEMENT: / / State Work Done <br /> w <br /> '- State Work,Done <br /> PUMP--REPAIR: v - - I <br /> k DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure `s <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 /> 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. <br /> �,. TITLE <br /> � :SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> E ADDITIONAL COMMENTS: PHASE .II/FINAL INSPECTION <br /> ,UJWE II GROUT INSPECTION <br /> INSPECTION BYt DATE a INSPECTION-BFftDATE/d,f� "7Y <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 4172 1M <br /> E H 1426 <br /> F <br />