Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> - 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued —JcF <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 Sate Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB{� ADDRESSILOCATION CENSUS TRACT <br /> Owner's' Name Ph 1 e I'f1 <br /> Address o� g C. t C�� City s <br /> Contractor's Name 1 ! <br /> 'License # Phone -53 <br /> TYPE OF WORK (Check) : NEW WELL '/k' DEEPEN ./ / RECONDITION I I DESTRUCTION /_7 <br /> PUMP INSTALLATION f-/-PUMP REPAIR / PUMP REPLACEMENT /7 <br /> j ! "Other — <br /> DISTANCE TO NEAREST:j SEPTIC TANK,-•,moi SEWER LINES. + PIT PRIVY <br /> 'SEWAGE DISPOSAL FIELD ' CESSPOOL/SEEPAGE PIT <br /> eI OTHERAl <br /> INTENDED USE TYPE OF WELL t CONSTRUCTION SPECIFICATIONS <br /> IndustrialXable Tool Dia. of Well Excavation i/ <br /> Domestic/private ;Drilled Dia.-, of Well Casing _ _�-(57/ <br /> f/ <br /> Domestic/public FDriven r Gauge of Casing E <br /> Irrigation -Gravel Pack. Depth of Grout- Seal . f <br /> ry Other L,/_ Rotary 'Type` of Grout * �a��rr�i t <br /> Other Other Information mc/Yt �/ <br /> PULP INSTALLATION: . Contractot�, - <br /> Type of Pump r s H.P. <br /> PUMP REPLACEMENT: <br /> State Work T3or►e ,�.. <br /> PUMP 'PAIR::, State Work'�Done� <br />�DFSTRUCTIQI� WELL:OF _ � -_ '�"`� a �� x'•-�' �.'",�-.. �_�r— ,_�'�' - �... _- <br /> , _., Well Diameter Approximate Depth <br /> *� Des°oribe Material and Procedure L,j, ` r <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 welV'constructidn. Within FIFTEEN DAYS ' <br /> after completion of my work on a new well, I will- furnish the San Joaquiin 'Local Health District a <br /> WELL DRILLERS REPORT -.of the well and notify them before putting the well-in use. The above h <br /> information``'is true to .the',best of my knowledge and belief. :. <br /> SIGNED ' + f ,( } <br /> TITLE <br /> RAW PLOT PLAN ON.;REVERSE SIDE # <br /> * FOR DEPARTMENT USE ONLY <br /> PHASE I E <br /> APPLICATION ACCEPTED °BY• - a_1DATE , <br /> ADDITIONALr COMMENTS <br /> PHASE II- GROUT INTPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY ' .w:,• DATE INSPECTION BY 7LA DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING-AND FINAL' INSPECTION. r <br /> L` H 1426 /'711 � <br />